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PREVENTION   OF   EPIDEMICS 


THE 

PREVENTION  OF  EPIDEMICS 


AND    THE 


CONSTRUCTION  AND  MANAGEMENT 
OF  ISOLATION   HOSPITALS 


BY 

ROGER    MCNEILL,    M.D.  Edin. 

D.P.H.  Camb. 

MEDICAL    OFFICER   OF    HEALTH    FOR   THE   COUNTY   OF   ARGYLL,    FORMERLY   RESIDENT   MEDICAL    OFFICER 

INFECTIOUS   HOSPITALS  OF   THE   METROPOLITAN    ASYLUMS    BOARD    AT   HOMERTON   AND 

DEPTFORD,    LONDON,    AND   H.M.S.    '  ATLAS '    AND    '  ENDYMION,'    GREENWICH 


WITH  ILLUSTRATIONS 


PHILADELPHIA 
P.    BLAKISTON,    SON    &    CO., 

IOI2  WALNUT  STREET 
1895 


V^oQ^'<^    ^i~CA\(K^\^^ 


PREFACE 

The  nature  of  infectious  diseases,  the  manner  in  which 
they  spread,  the  loss  and  misery  caused  by  them,  and 
the  measures  that  should  be  adopted  to  prevent  them, 
are  but  imperfectly  known  to  those  entrusted  with  the 
administration  of  the  laws  affecting  the  public  health. 
Even  members  of  the  medical  profession  who  have 
not  made  a  special  study  of  the  question  hardly  realise 
its  importance. 

In  the  following  pages  an  attempt  is  made  to  deal 
with  the  subject  in  so  far  as  it  affects  small  towns 
and  rural  districts.  In  the  principal  towns  every 
endeavour  is  now  being  made  to  cope  with  this 
difficult  problem,  but  in  many  small  towns  and  rural 
districts  little  in  the  way  of  preventive  measures 
has  hitherto  been  attempted.  And  it  has,  perhaps, 
not  yet  been  sufficiently  realised  that  as  long  as 
infectious  diseases  are  allowed  to  spread  in  the  small 
towns   and   rural    districts,   so  long  will  it   be  found 


PREVENTION  OF  EPIDEMICS 


to  be  impossible  to  prevent  epidemics  from  breaking 
out  in  more  populous  centres. 

Local  authorities  have  now  for  many  years  been  in 
existence,  whose  duty  it  is  to  devise  means  against  the 
spread  of  disease.  Yet  in  many  districts  little  has 
been  done  beyond  appointing  medical  officers  of 
health  to  advise  Local  Boards,  and  sanitary  inspectors 
to  carry  out  their  instructions.  The  necessary 
appliances  have  not,  as  yet,  been  provided.  It 
would  be  as  rational  to  attempt  to  put  down  crime 
by  merely  appointing  experts  who  should  investigate 
the  career  of  criminals,  and  write  interesting  and 
exciting  narratives  to  the  magistrates  and  judges 
regarding  them,  or  by  a  force  of  police  without  the 
lock-up  and  the  dungeon  behind  them,  as  it  is  to 
appoint  medical  officers  of  health  to  investigate  the 
origin  and  spread  of  infectious  disease,  and  sanitary 
inspectors  to  act  on  their  instructions,  without  pro- 
viding proper  appliances  for  the  isolation  and  dis- 
infection of  houses  and  patients. 

The  designation  "Isolation  Hospitals"  has  been 
adopted  on  the  title  -  page  in  preference  to  either 
"Fever"  or  "Infectious  Hospitals."  A  "Fever 
Hospital "    does   not  convey  a   pleasant   idea  to  the 


PREFACE  vii 

public  mind.  Too  often  have  such  buildings  been 
erected  during  a  period  of  panic,  and  in  the  face  of 
a  threatening  danger.  Isolation  Hospitals  are  still 
regarded  by  the  public  as  a  source  of  danger  to 
persons  living  in  their  vicinity.  It  is  not  known  that 
such  buildings  may  be  constructed  and  managed  in 
such  a  way  as  to  be  of  no  danger  whatsoever.  The 
existence  of  an  Isolation  Hospital  in  a  locality  has  not 
yet  come  to  be  regarded  by  the  public  as  a  guarantee 
that  proper  measures  are  being  taken  against  the 
spread  of  infection,  or  the  absence  of  such  a  building 
as  a  sign  that  persons  suffering  from  epidemic 
diseases  are  allowed  to  infect  the  community.  A 
person  suffering  from  an  infectious  disease  and  isolated 
in  an  Isolation  Hospital  is  placed  under  the  most 
favourable  conditions  for  his  own  recovery,  and  at 
the  same  time,  by  his  isolation,  he  is  prevented  from 
becoming  a  source  of  danger  to  others.  The  separa- 
tion of  the  infectious  sick  from  the  healthy  is  the 
primary  object  of  such  hospitals,  and  the  designation 
"  Isolation  Hospital "  conveys  this  idea  better  than 
either  "Fever"  or  "Infectious  Hospital."  With  a 
view  to  prevent  any  feeling  among  the  well-to-do 
against    being  removed    to    a    hospital,    it   might   be 


PREVENTION  OF  EPIDEMICS 


advisable  to  adopt  such  a  designation  as  "  Sanatorium  " 
or  "  Isolation  Home."  This  has  already  been  done 
in  some  parts  of  England. 

My  thanks  are  due  to  Dr.  Thorne  Thome,  Medical 
Officer  to  the  Local  Government  Board,  for  assisting 
me  to  get  information  regarding  several  hospitals,  and 
for  his  kind  permission  to  copy  hospital  plans  from 
his  report ;  to  the  architects  and  other  gentlemen 
mentioned  in  the  appendix,  for  supplying  me  with 
plans  and  photographs  of  hospitals,  as  well  as  other 
information  regarding  them  ;  and  to  Dr.  M'Naughton, 
Medical  Officer  for  the  county  of  Kincardine,  for 
assisting  me  in  revising  the  proof  sheets. 

ROGER  M'NEILL. 

Oban,  -iird  Oct.  1894. 


CONTENTS 

CHAPTER    I 

The  Dissemination  of  Infectious  Diseases 

Spread  of  infectious  diseases  due  to  want  of  proper  means  for  isolation  and 
disinfection — The  question  at  present  prominently  under  notice — Until 
recently,  nature  of  infection  not  understood — Importance  of  subject  not  yet 
fully  grasped  by  the  public — Inefficiency  of  means  due  to  want  of  know- 
ledge and  to  want  of  local  organisation — Isolation  Hospitals  in  England — 
Infectious  diseases  almost  always  present  in  populous  centres — Cause  of  this 
—  Isolated  localities  infected  by  towns — Towns  infected  again  in  return 
— Proper  means  provided  in  the  large  towns — Improved  remedial  measures 
necessary  in  small  towns  and  rural  districts  .  .  Pages  i-ii 

CHAPTER    II 

The  Influence  of  Effective  Measures  against  the 
Spread  of  Infection  " 

The  extent  and  fatality  of  future  epidemics — Many  infectious  diseases  more  pre- 
valent during  childhood — Adults  protected  by  a  previous  attack  not  liable  to 
suffer — In  future  means  for  preventing  disease  better  organised — Protective 
measures  of  two  kinds — Prevention  by  inoculation,  vaccination,  etc. — 
Repression  by  isolation,  disinfection,  etc. — Mortality  from  and  susceptibility 
to  infectious  diseases  at  different  ages — Typhus,  typhoid,  scarlet  fever, 
diphtheria,  measles,  whooping  cough,  smallpox — Infectious  diseases  less 
liable  to  spread  among  adults — With  exception  of  typhus  and  typhoid,  these 
diseases  more  fatal  in  infancy  and  childhood  .  .  .       12-32 

CHAPTER    III 

The  Gain  to  the  Community  through  the  Adoption  of  Effective 
Measures  against  the  Spread  of  Infection 

Population  of  Scotland,  1881  and  1S91 — Number  of  deaths  from  zymotic 
diseases — Actual  money  value  of  each  individual  member  of  community 
— Loss  by    death — Still    greater  loss    by    sickness — Probable    estimate  of 


PREVENTION  OF  EPIDEMICS 


amount  of  sickness  —  Consequent  interference  with  labour  during  sickness 
and  seclusion — Usual  course  followed  by  infectious  disease  in  a  family — 
Estimate  of  loss  to  a  family  from  two  cases — Ex^Dense  of  preventive  measures 
less  than  loss  incurred  by  sickness  and  mortality — Isolation  Hospital 
rate  in  reality  insurance  against  disease — Dangers  to  the  rich — Example 
—  Isolation  Hospitals  prevent  spread  of  disease  and  formation  of  new 
centres  of  infection — Discovery  and  extinction  of  infected  centres — Example 
— Isolation  Hospital  most  effective  means  known  against  spread  of 
infection — Majority  of  population  inhabit  houses  where  isolation  is  not 
practicable — By  means  of  Isolation  Hospitals  outbreaks  easily  kept  under 
control — Authorities  quoted  ....         Pages  33-54 


CHAPTER    IV 

The  Nature  of  Infection  and  its  Influence  on  the  Construction 
AND  Management  of  Isolation  Hospitals 

Air  of  hospital  ward  or  apartment  contaminated  by  gases — Organic  products — 
Micro-organisms — Sir  John  Simon  on  ill-kept  hospitals  —  Dr.  Burdon 
Sanderson  on  the  intimate  pathology  of  contagium — Progress  of  bacteriology 
— Authorities  quoted — Tubercle  bacillus  cause  of  consumption — Anthrax 
bacillus,  cause  of  woolsorter's  disease — Bacillus  of  diphtheria,  of  scarlet 
fever,  of  typhoid — Micro-organisms  demonstrated  in  cholera  and  other 
diseases — Micro-organisms  not  yet  demonstrated  in  typhus,  whooping  cough, 
or  measles — Micro-organisms  retain  vitality  outside  human  body — Agree- 
ment of  bacteriologists  and  epidemiologists — Authorities  quoted — Agents  of 
infection  in  some  diseases  less  capable  of  living  outside  body  than  others — 
Noxious  and  infectious  agents  to  be  guarded  against  in  the  construction  and 
management  of  Isolation  Hospitals — Absorption  of  by  walls  and  furniture — 
Spread  of  from  one  person  to  another — Treatment  of  surgical  cases  a  sensi- 
tive test  of  healthiness  of  wards     .....       55-77 


CHAPTER    V 

The  Establishment  and  Erection  of  Isolation  Hospitals — 

Preliminary 

Expense  of  erection  and  maintenance — Number  of  beds  per  1000  of  population — 
Large  towns — Small  towns  —  Rural  districts — Conveyance  of  patients — 
Distance — On  the  distance  depends  number  of  hospitals  provided  over  a 
definite  area — Authorities  quoted — Small  burghs  should  join  i^ural  districts — 
Suggested  additional  powers  to  County  Councils — Hospital  site,  nature  of 
— Area  of  site  dependent  on  width  of  sanitary  zone  and  design  of  building 
— The  sanitary  zone,  width  of — Experience  of  various  hospitals — Fever  and 
Smallpox  Hospitals  Commission,  Local  Government  Board  on  —  Distance 
between  pavilions — Area  covered  by  buildings — Size  of  Isolation  Hospitals 


CONTENTS 


determined  by  :  (i)  provision  for  sexes  ;  (2)  provision  for  different  infectious 
diseases;  (3)  provision  for  staff — Impossibility  of  isolating  different  in- 
fectious diseases  in:  (i)  one  ward;  (2)  among  non  -  infectious  cases  — 
Authorities  quoted  on  treatment  of  infectious  diseases  in  general  virards — 
Spread  of  infection  in  general  hospitals — Conclusion — Necessity  of  detached 
pavilions  and  advantages  of  one-storied  buildings — Authorities  quoted — Port- 
able hospitals — Resume  of  requirements  for  Isolation  Hospitals  Pages  78-113 


CHAPTER    VI 

Hospital  Construction 

The  administrative  block — The  wards — Ward  blocks — Foundation  of — Material 
of  building — Wood — Authorities  quoted — The  history  of  the  old  hospital 
ship  Dreadnought — Corrugated  iron  and  wood — Stone  or  brick — Inner 
covering  for  walls — Thickness  of  walls — Shape  of  wards — Circular  wards 
— Size  of  wards — Cubic  and  floor  space — Height  and  width  of  wards — 
Flooring — Windows  —  Window  space  —  Ventilation  and  heating — Nurse's 
room — Clothes  store  or  press — Bath-room — Discharging -room — Slop  sink 
— E.C.  or  W.C. — Water  supply — Drainage — Laundry  and  Wash-house — 
Disinfecting  chamber — Mortuary — Ashpit — Destructor  or  incinerator — Ward 
furniture  .......     114-149 


CHAPTER    VII 

Disinfection 

Provision  for  disinfection  and  washing — Daily  disinfection  and  cleaning — 
Periodical  disinfection  —  Fallow  wards — District  disinfection — Disinfection 
of  hospital  wards — Drs.  Parsons  and  Klein  on  disinfection  by  heat — Dry 
heat — Boiling  water — Steam — Penetrating  power  of  different  forms  of  heat 
— Injury  to  articles  from  heat — Koch  and  Wolf  Hiigel  on  disinfection — 
Chemical  disinfectants — Reliable  means  for  disinfection  within  reach  of  rural 
districts  for  Isolation  Hospitals  and  private  houses  .  .     150-174 


CHAPTER    VIII 

Remarks  on  Hospital  Management 

Hospital  committee  —  Medical  officers  —  Admission  book  —  Nurses  —  District 
nurses  —  Caretakers — Regulations  for  nurses — Regulations  for  visitors — 
Notices  to  friends — Designation  of  hospital — Ambulance — London  ambul- 
ance stations,  regulations  for        .  .  .  .  .     175-203 


PREVENTION  OE  EPIDEMICS 


CHAPTER    IX 

Private  Sanitary  Aid  Associations 

Evidence  by  Mrs.  Francis  Johnstone  before  Smallpox  and  Fever  Hospitals  Com- 
mission— Rules  of  the  Sanitary  Aid  Association  at  Hastings    Pages  204-213 


APPENDIX 


Hospital  Platis. 


The  Heathcote  Hospital,  Leamington 
Burgh  of  Warrington  Infectious  Diseases  Hospital 
Ealing  Local  Board  Isolation  Hospital 
Stonehouse  Isolation  Hospital,  Lanarkshire 
Hospital  for  Infectious  Diseases,  Sheffield 
Dunoon  and  Kilmun  Isolation  Hospital 
Plans  of  Isolation  Hospital  recommended  by  the  Local  Government 
Board  ...... 

Tarbert  Isolation  Home    ..... 

Dr.  Burdon  Sanderson's  Annular  Ward  for  Smallpox 


INDEX 


217 
223 
226 
228 
229 
232 

23s 
240 
242 

243 


CHAPTER    I 

The  Dissemination  of  Infectious  Diseases 

The  question  of  devising  proper  means  for  the  isola- 
tion and  treatment  of  cases  of  infectious  diseases  is 
at  present  prominently  before  the  public  mind,  and  in 
Scotland  is  under  the  direct  consideration  of  almost 
every  District  Committee  and  County  Council.  It  is 
of  even  more  than  national  importance.  Hitherto  the 
subject  has  nowhere  received  the  attention  it  deserved. 
Under  the  old  form  of  Local  Government  in  Britain  it 
was  scarcely  possible  to  make  much  advance  in  this 
direction.  Until  a  comparatively  recent  period  the 
nature  of  infectious  diseases  and  the  manner  in  which 
they  spread  were  but  little  inquired  into.  It  was 
believed  that  "  the  pestilence  that  walketh  in  darkness 
and  the  destruction  that  wasteth  at  noon-day  "  origin- 
ated and  spread  far  beyond  human  ken.  That  "pre- 
vention is  better  than  cure "  was  a  byword,  but 
its  scope  was  not  fully  understood.  Persons  with 
weak  chests  knew  that  certain  precautions  prevented 
them  from  catching  cold  ;  the  rheumatic  were  aware 
that  living  in  a  damp  climate  or  in  damp  houses  should 


PREVENTION  OF  EPIDEMICS 


be  avoided ;  and  persons  of  a  bilious  temperament 
knew  that  adherence  to  a  certain  diet  and  regimen 
prevented  the  frequency  of  their  attacks,  but  the  fact 
that  various  diseases  might  be  prevented  if  not  ex- 
tinguished on  a  large  scale,  was  not  fully  grasped. 
Gradually  it  began  to  be  known  that  medical  men  who 
devoted  their  time  and  energy  towards  the  improve- 
ment of  the  public  health  were  doing  something  to 
prevent  the  population  from  dying  at  the  same  rate  as 
was  formerly  the  case.  Newspapers  drew  attention  to 
the  fact  that  in  the  large  towns  where  more  attention 
was  paid  to  this  question,  the  rate  of  mortality  was 
gradually  getting  lower.  It  is  not  yet,  however, 
sufficiently  well  known  that  the  lowering  of  the  rate  of 
mortality  in  the  towns  is  due  to  a  large  extent  to  the 
measures  taken  to  prevent  the  more  fatal  of  the  in- 
fectious diseases  from  spreading.  The  improvement 
in  the  sanitary  condition  of  the  houses  of  the  poor,  the 
prevention  of  overcrowding,  the  care  taken  to  provide 
pure  water  and  unadulterated  food,  and  the  advance 
in  the  general  wellbeing  of  the  population,  have 
directly  improved  the  public  health,  and  have,  further- 
more, rendered  persons  less  liable  to  suffer  from,  and 
better  able  to  withstand  attacks  of,  infectious  and  other 
diseases.  Yet,  if  measures  were  not  taken  to  prevent 
the  spread  of  infection  in  the  towns,  the  mortality 
would  be  much  greater  than  is  now  the  case.  In 
rural  districts,  until  a  comparatively  recent  period,  this 
question  was  almost  entirely  neglected,  and  even  yet, 
over  a  great  part  of  the  country,  measures  are  carried 


INEFFICIENT  PROVISION  FOR  ISOLATION  3 

out  in  a  very  imperfect  and  slipshod  fashion.  Even 
to-day  the  advent  of  an  epidemic  sometimes  results  in 
a  panic.  Unseemly  huts,  meant  for  Isolation  Hospitals, 
defective  in  structure  and  general  arrangements,  are 
sometimes  hurriedly  run  up  during  the  progress  of  an 
epidemic.  Upon  the  advent  of  an  epidemic  a  proper 
site  for  a  hospital  can  rarely  be  obtained.  Buildings 
hurriedly  erected  are  often  found  in  very  unsuitable 
localities,  and  frequently  present  a  forbidding  appear- 
ance. They  have  been  badly  built,  warmed,  and 
ventilated,  far  from  any  other  dwelling,  and  sometimes 
even  without  a  road.  Hitherto  it  was  in  very  rare 
instances  indeed  that  a  proper  ambulance  carriage  was 
provided  for  the  conveyance  of  patients  to  a  hospital. 
An  old  rickety  jolting  cab,  in  which  a  patient  could 
only  sit,  was  considered  quite  suitable,  although  it 
rendered  the  conveyance  of  severe  cases  from  a 
distance  extremely  dangerous,  if  not  impossible.  It 
cannot  therefore  be  wondered  at,  that  persons  whose 
friends  or  relatives  suffered  from  infectious  diseases 
hesitated  to  send  them  by  such  means  into  such  build- 
ings. As  might  be  expected,  medical  men  hesitated 
to  advise  their  patients  to  take  advantage  of  such 
provision. 

The  inefficiency  of  the  provision  for  the  isolation  of 
infectious  diseases  in  rural  districts  was,  to  a  certain 
extent,  due  to  want  of  knowledge  on  the  part  of  Local 
Authorities  and  partly  to  the  smallness  of  the  ratable 
area  under  each  Parochial  or  Local  Board.  A  little 
parish  could  hardly  afford  to  provide  a  separate  I  sola- 


PREVENTION  OF  EPIDEMICS 


tion  Hospital,  while  local  jealousies  and  want  of  cohesion 
frequently  prevented  the  erection  of  joint  or  combina- 
tion hospitals.     This  state  of  matters  has  been  consider- 
ably improved,  more  particularly  in  the  case  of  Scotland, 
by  the  creation  of  larger  districts,  with  District  Com- 
mittees as  Local  Authorities,  more  or  less  under  the 
eye  of  the  County  Councils.     In  1 879  the  Local  Govern- 
ment  Board  got   a   return   of  Isolation    Hospitals    in 
England.^     Of  1593  Sanitary  Authorities  in  England 
and  Wales   it  was  found  that  only  296  had  provided 
means  for  the  isolation  of  infectious  diseases.      In  many 
instances  the  hospital  provision  reported  was  such  in 
name  only.      A  large  number  of  Isolation  Hospitals 
have  been  erected  in  England  since  that  time.      Still, 
"notwithstanding  the  phenomenal  growth    of   public 
opinion  in  regard  to  this  question  in  recent  years,  many 
important  centres  of  population  in  the  provinces  and  as 
yet  a  large  proportion  of  the  smaller  towns,  as  well  as 
the   majority  of  rural  communities,   have  not  moved 
in  the  matter."  2     In  a  paper  read  in  the  Architectural 
Section    of    the    Seventh   International    Congress    of 
Hygiene  and  Demography,  held  in  London  in  1891, 
Dr.  Thorne  stated  :   "I  find  that  since  that  date  (1881) 
loans  amounting  in  all  tO;^448,769  have  been  granted 
to  over  a  hundred  Sanitary  Authorities  for  the  provision 
of  Isolation  Hospitals  .   .   .  and  I  am  probably  correct 
in  stating  that  some  adequate  means  for  the  isolation 


1  loth  Report  of  Local  Government  Board,  1880-81.      Supplement  to  p.  5, 
reissued  1893. 

2  Burdett,  Hospitals  and  Asyliuns  of  the  World,  vol.  iii.  p.  102. 


PREVALENCE   OF  INFECTIOUS  DISEASES  IN  TOWNS  5 

of  infectious  diseases  are  now  possessed  by  at  least  400 
urban,  rural,  and  port  Sanitary  Authorities." 

Under  the  Public  Health  Act,^  Local  Authorities 
may  provide  within  their  districts  hospitals  for  the 
reception  of  the  sick  for  the  use  of  the  inhabitants. 
Provision  is  also  made  whereby  Local  Authorities  are 
authorised  to  "borrow  for  the  purpose  of  so  building 
or  otherwise  providing  permanent  hospitals  on  the 
security  of  the  general  assessments."  ^  Money  for  this 
purpose  can  be  borrowed  at  a  low  rate  of  interest 
payable  by  small  instalments  extending  over  a  number 
of  years. 

Wherever  a  large  population  is  crowded  together, 
as  in  the  principal  towns,  where  the  individual  mem- 
bers are  liable  to  come  into  daily  contact,  and  where 
frequent  communication  exists  with  other  populous 
places,  infectious  disease  of  one  kind  or  another  almost 
always  prevails.  The  seeds  of  infection  in  such  places 
are  probably  never  extinct.  Clothes,  articles  of  furni- 
ture, and  parts  of  premises  in  which  infectious  dis- 
ease prevailed,  sometimes  escape  thorough  disinfection 
and  cleansing.  Persons  who  are  unfortunate  enough 
to  come  in  contact  with  these  articles,  or  to  visit  or 
live  in  such  houses,  are  liable  to  become  infected. 
These  infect  others,  and  so  disease  spreads.  The 
movements  of  the  individual  members  of  the  com- 
munity are  so  devious  and  intricate,  the  communica- 


1  See  Sect.    131,  P.  H.  Act  for  England,  1872;    and  Sect.  39,  P.  H.  Act 
for  Scotland,  1867. 

2  P.  H.  Scotland  Amendment  Act,  1871  ;  English  P.  H.  Act,  1875. 


PREVENTION  OF  EPIDEMICS 


tion  between  different  persons  so  frequent  and  intimate, 
the  seeds  of  infection  so  tenacious  of  life,  and  so  liable 
to  stick  to  all  manner  of  things,  that  unless  the  utmost 
care  is  taken  infectious  disease  will  spread  from  a 
small  centre  and  do  infinite  mischief.^  The  misery 
following  epidemics  of  infectious  diseases  among  the 
poorer  classes  of  the  population  cannot  well  be  calcu- 
lated. The  rate  of  mortality  from  infectious  disease  is 
not  equally  distributed  among  all  classes  of  the  popula- 
tion. The  poor,  living  In  unhealthy  dwellings,  and  badly 
nourished,  suffer  most  severely.  In  many  cases  where 
a  wage-earning  member  of  a  family  dies,  the  survivors 
are  brought  to  the  verge  of  starvation,  and  thus  become 
dependent,  perhaps  for  many  years,  for  subsistence  on 
parochial  relief. 

Only  those  who  make  a  special  study  of  this  ques- 
tion can  be  fully  impressed  with  its  importance.  In 
towns,  people  know  only  their  immediate  neighbours. 
In  rural  districts  the  population  is  often  sparse,  and 
the  means  of  communication  slow.  The  sufferings  of 
a  family  in  one  locality  are  heeded  but  for  a  brief 
space  of  time,    and    by    their   immediate    neighbours 

1  The  following  cases,  recorded  by  Dr.  Birdwood,  medical  superintendent  to 
the  hospital  ships,  Long  Reach,  Kent,  illustrate  this.  A  dock  labourer  was  the 
first  of  a  group  often  patients  admitted  into  the  smallpox  hospital  ships,  London. 
He  did  not  know  the  source  of  his  infection.  His  brother,  a  little  girl,  and  a 
man  living  in  the  same  house,  were  infected.  A  man  not  employed  by  any 
sanitary  authority  came  to  disinfect  the  house,  and  a  woman  from  Camberwell 
came  to  visit  her  dying  daughter  at  the  same  house  ;  they  were  both  admitted 
suffering  from  smallpox.  The  potman  at  the  public  house  frequented  by  the 
[dock  labourer]  was  the  earliest  one  to  recognise  the  nature  of  the  disorder  with 
which  he  was  afflicted.  The  potman,  his  wife,  a  fellow-lodger,  and  a  lad  who 
daily  called  for  beer,  followed.  See  Report  of  Statistical  Committee  of  Metro- 
politan Asylums  Board,  iSgi,  p.  lo.     Numerous  other  instances  might  be  given. 


TOWNS  INFECT  RURAL  DISTRICTS 


only.  Infectious  diseases  have  visited  them  periodic- 
ally for  ages,  and  much  as  they  suffer  and  dread  these, 
they  look  upon  them  as  part  of  the  natural  order  of 
things.  It  seldom  occurs  to  any  one  that  such  misery 
and  death  might  be  entirely  prevented. 

The  prevalence  of  infectious  disease  in  the  large 
towns  is  a  grave  danger  to  all  places  in  frequent  com- 
munication with  them.^     Isolated  cases  keep  breaking 

1  In  1892  Dr.  M'Lintock,  county  medical  officer  for  Lanarkshire,  reported  a 
fatal  case  of  smallpox  at  Newmains,  and  stated  that  the  source  of  infection  was 
ultimately,  and  with  difficulty,  traced  by  Mr.  Dobson  (the  sanitary  inspector)  to 
a  daughter  living  in  Glasgow,  who  had  been  visiting  her  parents  a  fortnight  pre- 
vious to  the  rash  on  her  mother  (Second  Annual  Report,  p.  65). 

Dr.  Maxwell  Ross,  county  medical  officer,  Dumfriesshire,  states  that  the 
parishes  of  Annan,  Kirkpatrick-Fleming,  and  Middlebie,  suffered  most  from 
[scarlet  fever]  in  the  Annan  district,  and  that  some  of  the  cases  were  introduced 
from  Hoddam.  The  Annan  hiring  fair  appeared  to  be  responsible  for  certain  of 
the  cases  which  occurred  both  in  Annan  and  Kirkpatrick-Fleming.  Into  the 
same  district  measles  was  introduced  from  Carlisle  (First  Annual  Report,  pp. 
17  and  20). 

Dr.  M'Vail,  county  medical  officer  for  Dumbartonshire,  states,  in  regard  to  an 
outbreak  of  scarlet  fever  on  board  the  training  ship  Emp7-ess  in  the  Gareloch  : 
"  The  first  case  was  that  of  a  new  boy  who  had  come  from  Glasgow  on  September 
loth;"  and  in  regard  to  diphtheria  in  Cumbernauld  parish,  "the  disease  appeared 
to  have  been  brought  from  Edinburgh"  (First  Annual  Report,  pp.  51  and  54). 

Dr.  Bruce,  county  medical  officer  for  Ross-shire,  states,  in  regard  to  an  out- 
break of  measles  in  the  camp  of  the  Inverness-shire  Militia,  at  Muir  of  Ord  : 
"  The  origin  of  the  epidemic  was  distinctly  traced  to  Harris,  and  to  the  West  it 
unfortunately  was  carried  afresh  "  (First  Annual  Report,  p.  40). 

Dr.  Ogilvie  Grant,  county  medical  officer  for  Inverness-shire,  referring  to 
outbreaks  of  a  "very  severe  and  malignant  type  of  measles"  in  Harris,  North 
Uist,  and  Skye,  states  :  "  Infection  was  traced  by  Dr.  Mackenzie  to  two  sources 
— (i)  The  disbanding  of  the  Inverness-shire  Militia;  (2)  Direct  infection  from 
the  adjoining  parish  of  Harris.  .  .  .  Dr.  Dewar  of  Portree  states  that  one  of  the 
crew  of  the  s.s.  Locheil  was  infected  from  another  source,  viz.  from  a  militiaman 
returning  home  from  Muir  of  Ord,  who  was  travelling  in  the  eruptive  stage  of  the 
disease"  (First  Annual  Report,  p.  11). 

Dr.  Watt,  county  medical  officer  for  Aberdeenshire,  states,  with  regard  to 
scarlet  fever  at  Newhills :  "  Many  of  these  cases  were  traced  to  infection  spreading 
from  the  town,  where,  from  August  to  December,  a  very  severe  epidemic  was 
raging  "  (First  Annual  Report,  p.  8). 

In  1S92  I  reported  that  a  person  suffering  from  "typhoid  fever  at 
Innellan    is  believed  to  have   become  infected   while  examining  old   properties 


PREVENTION  OF  EPIDEMICS 


out  every  year  in  localities  visited  by  excursionists 
from  the  towns  at  the  various  holiday  seasons. 

Unless  every  care  is  taken,  each  individual  case  is 
liable  to  start  an  epidemic. 

The  towns,  however,  are  not  alone  at  fault.  The 
rural  districts  and  smaller  burghs  also  infect  the  larger 
towns.  Epidemics  of  typhoid  fever  ^  have  frequently 
been  traced  to  infected  milk  supplied  from  the  country. 
Epidemics  of  scarlet  fever  have  been  traced  to  the 
same  source.^  The  emigration  of  persons  from  in- 
fected houses  in  rural  districts  during  the  progress  of 
epidemics  also  frequently  infects  the  towns.  It  will 
thus  be  seen  that  the  towns  and  the  rural  districts,  in 


in  Glasgow,  where  the  disease  is  said  to  have  prevailed."  ..."  Measles  was 
introduced  from  Newcastle  to  Kilmun,  and  from  Rothesay  to  Ormidale  "... 
' '  And  from  Glasgow  to  Inverary  "  ..."  An  outbreak  of  typhoid  fever  in  the 
island  of  Jura  was  traced  to  a  young  man  who  came  home  after  suffering  from  the 
disease  in  Glasgow  "  (Second  Annual  Report,  pp.  50  and  56,  and  First  Annual 
Report,  p.  7). 

1  An  epidemic  of  typhoid  fever  in  Plymouth  was  traced  by  Dr.  F.  M. 
Williams,  medical  officer  of  health,  to  the  milk  supplied  from  a  farm  in  Plympton 
district  {British  Medical  Journal,  1892,  p.  1157).  Typhoid  fever  was  traced  to 
consumption  of  lemonade,  ices,  and  spirits,  which  have  been  made  of,  or  diluted 
with,  water  from  a  sewage-polluted  well  (Mr.  G.  H.  Fosbroke,  Treatise  on 
Hygiene  and  Public  Health,  vol.  ii.  p.  324 :  Stevenson  and  Murphy).  An  epi- 
demic of  typhoid  fever  at  Whitchurch  in  1871  was  traced  to  the  introduction  of 
the  poison  by  a  young  person  who  came  into  the  place  ailing,  and  ultimately  died 
of  typhoid  fever  (Report  of  Medical  Officer  Local  Government  Board,  1872). 

2  An  outbreak  of  scarlet  fever,  associated  with  diphtheria  and  sore  throat,  was 
traced  by  Dr.  Parsons  to  the  milk  supply  in  Macclesfield  rural  and  urban  sanitary 
districts  (Report  Medical  Officer  Local  Government  Board,  1889,  p.  84). 
Scarlet  fever  in  Marylebone,  London,  in  1885-86,  was  traced  by  Mr.  Power  to 
milk  supplied  from  Hendon  (Report  by  Dr.  Klein  in  the  Report  by  the  Medical 
Officer  of  the  Local  Government  Board,  1887,  p.  203).  An  epidemic  of  scarlet 
fever  in  Glasgow  in  August  1892  was  traced  by  Dr.  Russell  to  milk  supplied  from 
a  dairy  farm  in  Renfrewshire  (Report  on  an  Outbreak  of  Scarlet  Fever  in  Glas- 
gow, by  Drs.  J.  B.  Russell,  A.  K.  Chalmers,  and  E.  Klein,  1893).  An  out- 
break of  diphtheria  at  Yorktown,  Camberley,  was  traced  by  Mr.  W.  H.  Power"  to 
the  milk  supply  (Report  of  Medical  Officer  Local  Government  Board,  1886, 
p.  311).      Numerous  other  instances  might  be  given. 


RURAL  DISTRICTS  INFECT   TOWNS 


SO  far  as  the  spreading  of  infectious  disease  is  con- 
cerned, act  and  react  on  each  other. 

Innumerable  centres  scattered  over  a  wide  area  in 
rural  districts  and  villages  converge  upon  the  large 
towns  and  infect  them.  On  the  other  hand,  from  the 
towns,  thousands  of  infected  cases  radiate  over  the 
country,  infecting  individuals  and  creating  new  centres 
from  which  the  disease  may  again  spread  and  return  to 
them.  In  the  towns  **  couriers  arrive  bestrapped  and 
bebooted,  bearing  joy  and  sorrow  in  pouches  of  leather  ; 
there,  top-laden,  with  four  swift  horses,  rolls  in  the 
country  baron  and  his  household  ;  here,  on  timber  legs, 
the  lamed  soldier  hops  painfully  along  begging  alms. 
A  thousand  carriages  and  wains  and  cars  come 
tumbling  in  with  food,  with  young  rusticity,  and 
other  raw  produce,  animate  or  inanimate,  and  go 
tumbling  out  again  with  produce  manufactured  "  ;  and 
thus  infectious  diseases  as  well  as  other  commodities 
are  exchanged. 

Dr.  Russell,^  Medical  Officer  of  Health  for  the  City 
of  Glasgow,  states  : — "  In  my  experience  epidemics 
never  cover  the  whole  area  of  the  community  at  their 
incidence.  They  begin  in  one  district,  and  if  not 
checked,  they  eat  their  way  through  the  mass,  while,  if 
they  are  vigorously  attacked,  they  may  be  stamped  out 
in  that  district.  If  they  begin  within  the  municipal 
limits  [of  Glasgow],  the  whole  repressive  force  of  the 
municipality  is   directed  to  the  spot.      If  they  begin 

^  Transactions  of  the   Epidemiological  Society  of  London,   1881-82,   pp.    84 
and  85. 


PREVENTION  OP  EPIDEMICS 


outside  these  limits,  the  appHances  of  the  petty  burgh, 
even  at  their  best,  cannot  command  adequate  resources, 
and  we  can  only  stand  by  to  quench  such  sparks  as 
may  be  projected  into  our  premises." 

The  towns,  however — more  particularly  the  large 
towns — have  as  a  rule  done  their  part  in  trying  to  pro- 
vide ways  and  means  to  prevent  the  spread  of  infection 
within  the  town  and  beyond  its  borders.  From  the 
very  nature  of  the  case,  the  lead  in  preventing  the 
spread  of  infectious  disease  would  begin  there.  There 
the  evil  was  ever  present,  and  the  amount  of  wealth 
centred  within  a  limited  area  justified  the  expenditure 
of  large  means  to  cope  with  it.  The  question  was  not 
so  pressing  in  rural  districts.  Infectious  disease  here 
spreads  more  slowly,  but  its  victims  will  be  picked  out 
all  the  same.  It  will  thus  be  seen  that,  however  well 
the  towns  are  managed  and  guarded  in  this  respect, 
they  cannot  be  kept  free  of  infection  so  long  as  they 
are  supplied  with  disease  from  the  country.  Remedial 
measures  for  country  districts  and  small  towns,  there- 
fore, become  essential,  not  merely  for  the  protection 
of  the  rural  population,  but  of  the  urban  population 
as  well. 

Infectious  diseases  may  be  compared  to  a  fire,  and 
the  population  to  the  combustible  material.  In  towns 
the  combustible  material  is  lying  in  heaps,  and  when 
the  spark  falls  the  spread  and  destruction  are  more 
rapid. 

But  even  in  more  sparsely -peopled  districts  the 
material  is  sufficiently  continuous  to  enable  the  flame 


ISOLATION  PREVENTS  SPREAD   OF  INFECTION     ii 

to  spread,  if  with  slower,  yet  with  equally  fatal  steps. 
In  the  case  of  infectious  disease,  the  spark  cannot  be 
immediately  extinguished,  as  may  be  done  in  the  case 
of  a  fire  ;  but  fortunately  it  can  be  removed  or  isolated. 
The  patient  may  be  separated  from  the  healthy  if  a 
case  occurs  in  a  house  of  sufficient  accommodation, 
and  if  not  he  can  be  removed  to  a  hospital,  if  such 
accommodation  is  provided. 


CHAPTER    II 

The  Influence  of  Effective  Measures  against  the  Spread 
OF  Infection  on  the  Extent  and  Fatality  of  Future 
Epidemics 

Many  of  the  infectious  diseases  prevalent  among  the 
community  are  diseases  of  children,  and  therefore  many 
of  the  adult  population  are  protected  by  a  previous 
attack.  It  might  accordingly  be  argued  that  if  children 
are  prevented  from  getting  such  diseases,  the  popula- 
tion will  after  a  time  become  more  liable  to  suffer  from 
more  severe  epidemics,  that  a  larger  number  will  be 
liable  to  catch  those  diseases,  and  that  it  will  become 
impossible  to  prevent  them  from  spreading.  No  doubt 
this  is  true  to  a  certain  extent,  but  meantime  our 
organisation  for  the  prevention  of  disease  will  become 
more  perfect.  The  centres  from  which  such  diseases 
spring  will  become  more  isolated  and  less  numerous. 
The  sanitary  condition  of  the  houses  of  the  poor  will 
be  better.  Scientific  men  are  not  only  engaged  in 
tracing  the  source  of  such  diseases  and  in  framing 
measures  to  prevent  them  from  spreading,  but  great 
strides  have  already  been  made  in  devising  means 
whereby  the  population  may  be  rendered  almost  proof 
against  even  the  most  infectious  of  them.     Vaccination 


EFFECT  ON  FUTURE  EPIDEMICS  13 

and  re-vaccination  have  almost  extinguished  smallpox. 
Dr.  Watt  found  that  the  deaths  from  smallpox  were 
reduced  to  one-fifth  of  their  original  number  by  vac- 
cination. Before  1800,  20  out  of  every  100  born, 
excluding  still-born,  perished  by  this  dreadful  malady.^ 
This  disease  is  no  longer  a  periodical  scourge  decim- 
ating the  population.  Even  if  it  breaks  out  in  isolated 
localities,  it  can  easily  be  kept  under  control.  This  has 
been  amply  proved  in  Scotland  during  the  past  year. 
Smallpox  broke  out  in  various  places  in  the  country, 
but  in  no  instance  was  it  allowed  to  spread  into  any- 
thing like  an  epidemic.  Typhus  fever  is  no  longer  so 
prevalent  as  it  once  was.  It  only  occurs  in  isolated 
spots  where  the  rules  of  health  are  neglected,  where 
human  beings  are  badly  fed,  in  overcrowded,  dirty 
dwellings  without  sufficient  ventilation.  Pasteur  has 
been  successful,  by  means  of  inoculation,  in  protecting 
many  from  an  attack  of  hydrophobia.  By  the  same 
means  animals  have  been  rendered  immune  to  the 
action  of  the  anthrax  bacillus.  Infectious  diseases  are 
thus  as  it  were  between  two  fires.  In  front  we  have 
our  local  authorities,  with  their  army  of  medical  officers 
of  health  and  sanitary  inspectors  doing  their  utmost  to 
check  the  onward  march  of  these  diseases,  while  at 
the  rear  we  have  bacteriologists  attacking  them  in 
their  very  citadel,  not  without  hope  of  being  able 
ultimately  to  extinguish  them  one  by  one.  In  addition 
to  this,  by  the  gradual  improvement  in  the  wellbeing 

-'■  Farr,   Vital  Stat.,  p.  322.     Enquiry  into  the  Relative  Mortality  of  the  Prin- 
cipal Diseases  of  Children  in  Glasgow,  by  Dr.  Watt,  181 3. 


14  PREVENTION  OF  EPIDEMICS 

of  the  population,  by  the  providing  of  purer  water, 
healthier  food,  and  more  sanitary  dwellings,  epidemics 
of  some  diseases  appear  to  be  less  fatal  or  of  a  milder 
type  than  was  formerly  the  case. 

It  might  also  be  argued,  that  infectious  diseases  are 
milder  in  children,  and  that  if  children  are  prevented 
from  contracting  these  diseases,  as  adults  they  may  get 
them  in  severer  forms  and  die  in  proportionally  higher 
numbers.  This  is  true  to  a  certain  extent,  and  in  a 
very  marked  degree,  of  typhus  fever.  If  one  hundred 
children  under  five^  years  of  age  suffered  from  this 
disease,  about  seven  of  them  would  die ;  if  the  same 
number  aged  from  ten  to  fifteen  were  to  get  it,  only 
between  two  and  three  would  die  ;  if  the  hundred  were 
about  thirty  years  of  age,  about  from  twenty  to  thirty 
would  prove  fatal ;  if  about  fifty,  fifty-four  would  die  ;  and 
if  over  sixty,  sixty-seven  would  succumb ;  yet  no  one 
has  yet  had  the  courage  to  recommend  that  efforts 
should  be  made  to  spread  typhus  fever  among  children. 
It  is  no  longer  universally  prevalent,  and  the  localities 
from  which  it  emanates  are  so  few  that  it  is  possible  to 
check  its  spread.  As  age  advances  the  liability  to 
catch  typhus  fever  decreases,  although  the  disease  is 
more  fatal  in  adults. 

The  succeeding  table  ^  gives  the  admissions  of 
persons  suffering  from  typhus  fever,  the  percentage 
of  admissions,  and  rate  of  mortality,  at  different  ages 

1  Murcliison,    Coniimied  Fevers,   p.    236.      Report  of  Statistical  Committee 
of  Metropolitan  Asylums  Board,  1890. 

2  Report  of  Statistical   Committee   of  Metropolitan  Asylums  Board,    1890, 
p.  14. 


MORTALITY  AT  DIFFERENT  AGES— TYPHUS 


15 


in  the  Hospital  of  the   MetropoHtan  Asylums  Board 
from  1 872-1890. 

Typhus  Fever 
Hospital  of  the  Metropolitan  Asylums  Board,  1872-1890 


Ages. 

Admissions. 

Percentage 

of  Total 
Admissions. 

Deaths. 

Mortality 

per  cent  of 

Admissions  at 

Same  Age. 

Under  5 

86 

4.05 

2 

2.32 

5-10 

242 

I  1.40 

I 

0.41 

10-15 

370 

17.44 

14 

3.80 

15-20 

352 

16.59 

28 

8.04 

20-25 

239 

I  1.26 

49 

20.50 

25-30 

152 

7.16 

34 

22.36 

30-35 

159 

7.49 

47 

29.74 

35-40 

129 

6.08 

47 

36.43 

40-45 

168 

7.92 

81 

48.21 

45-50 

95 

4-47 

42 

44.21 

50-55 

60 

2.82 

36 

60.00 

55-60 
And      ) 
upwards  j 

32 
■hi 

1.50 

1.74 

24 

27 

75.00 
72.97 

Totals     . 

2121 

432 

20.36 

The  following  table  ^  gives  the  same  data  in  regard 
to  the  admissions  into  the  London  Fever  Hospital 
from  1 848- 1 8  70. 

■'  Murchison,  Continued  Fevers,  3rd  ed.,  p.  237. 


i6 


PREVENTION  OF  EPIDEMICS 


Typhus  Fever 
London  Fever  Hospital,  1 848-1 870 


Ages. 

Admissions. 

Deaths. 

Percentage 

of  Total 
Admissions.! 

Mortality 

percent  of 

Admissions  at 

Same  Age. 

Under  5 

5-9 
10-14 
15-19 
20-24 
25-29 
30-34 
35-39 
40-44 

45-49 
50-54 

55-59 
60-64 
65-69 
70-74 

75-79 
80  and    ) 
upwards  ) 
Age  not  ) 
specified  j 

234 
I  196 
2189 
2932 
2400 
1727 
I518 

1458 

1507 

1039 

790 

441 

400 

188 

84 

32 

3 
130 

15 

43 

50 

131 

248 

262 

312 

378 

464 

442 

392 

238 

241 

142 

61 

27 

3 
8 

1.29 

6-59 
12.06 
16.16 

13-23 
9.52 
^■2,6 
8.03 
8.30 
5-72 

4-35 

2.42 

2.20 

1.03 

.46 

-17 

.01 

6.69 

3-59 
2.28 
4.46 

10-33 
15.17 
20.55 
25-92 
30.79 
42-54 
49.62 

53-96 
60.25 

75-53 
72.62 

84-37 
100. 

6.15 

Totals    . 

18,268         3457 

18.92 

In  typhoid  fever,  again,  the  death-rate  among  child- 
ren under  ten  years  of  age  is  less  than  half  that  among 
adults  over  thirty.  Children  are,  however,  very  liable 
to  contract  this  disease  if  they  come  in  the  way  of 
infection,  whereas  persons  of  maturer  years  are  less 
susceptible  to  it.  That  is  to  say,  if  an  equal  number 
of  children  and  of  persons  of  mature  years  were 
exposed  equally  to  the  infection  of  typhoid  fever,  the 
vast  majority  of  the  children  would  contract  the  disease, 
whereas  the  vast  majority  of  the  adults  would  suffer  no 

^   In  reckoning  the  percentage  of  admissions  at  different  ages,  the  130  cases 
in  which  the  age  is  not  specified  are  deducted  from  the  total. 


MORTALITY  AT  DIFFERENT  AGES— TYPHOID       17 

harm.  Of  6960  cases  of  typhoid  fever  admitted  into 
the  Metropohtan  Asylums  District  Board  Hospitals 
before  1890,  2718  were  under  fifteen  years  of  age, 
whereas  only  255  were  over  forty. 

As  age  advances  the  liability  to  catch  typhoid  fever 
appears  to  decrease.  "In  children  the  liability  to 
invasion  from  greater  susceptibility  rather  than  from 
greater  exposure  to  it  causes  a  maximum  proportion  of 
attacks."  ^ 

The  succeeding  table  ^  gives  the  admissions  of  per- 
sons suffering  from  typhoid  fever,  the  percentage  of 
admissions,  and  rate  of  mortality,  at  different  ages  in 
the  hospitals  of  the  Metropolitan  Asylums  Board 
from  1 872- 1 890. 


Ages. 

Admissions. 

Percentage 

of  Total 
Admissions. 

Deaths. 

Mortality 

per  cent  of 

Admissions  at 

Same  Age. 

Under  5 

201 

2.88 

28 

13-93 

5-10 

894 

12.84 

77 

8.61 

10-15 

1623 

23-31 

217 

13-37 

15-20 

1604 

23.04 

295 

18.38 

20-25 

1054 

15.14 

21  I 

20.02 

25-30 

689 

9.89 

163 

23.65 

30-35 

401 

5.76 

107 

26.68 

35-40 

239 

3-43 

63 

26.36 

40-45 

126 

1. 81 

28 

22.23 

45-50 

72 

1.03 

22 

30.56 

50-55 

33 

•47 

I  I 

33-34 

55-60 

12 

•17 

6 

50.00 

And         ) 
upwards  j 

12 

•17 

4 

30.34 

Totals    . 

6960 

1232 

17.70 

^   Farr's  Statistics,  p.  391. 
2  Report  of  Statistical  Committee  of  Metropolitan  Asylums  Board,  1890,  p.  13. 

C 


i8 


PREVENTION  OF  EPIDEMICS 


The  following  table  gives  the  same  data  in  regard 
to  the  admission  into  the  London  Fever  Hospital^ 
from  1848  to  1870: — 


Ages. 

Admissions. 

Percentage 

of  Total 

Admissions. 2 

Deaths 

Mortality 

per  cent  of 

Admissions  at 

Same  Age. 

Under  5 

5-  9 
10-14 
15-19 

20-24 
25-29 
30-34 
35-39 
40-44 

45-49 
50-54 

55-59 
60-64 
65-69 
70-74 

75-79 
Age  not  ) 
specified  j 

58 

558 

II74 

1588 

I  164 

600 

297 

201 

124 

64 

36 

20 

20 

5 
2 

.98 
9.44 
18.16 
26.86 
19.69 
10.15 
5-36 

3-40 
2.09 
1.08 
.60 
•33 
•  33 
.08 

•03 
1.30 

7 
63 
151 
246 
238 
123 
76 

S3 

33 

M 

8 

9 
9 
2 

I 
I 

12.06 
11.28 

12.86 
15.48 
20.36 
20.50 

25.59 
26.36 
26.61 
21.87 
22.22 
45.00 
45.00 
40.00 

50.00 
1.29 

Totals    . 

5988 

1034 

17.26 

Nearly  half  the  cases  were  between  15  and  25  years 
of  age,  more  than  ^th  under  15,  ^th  above  30,  while 
only  I  in  every  71  exceeded  50. 

Of  7348  cases  of  typhoid  fever  reported  to  the 
French  Academy  from  different  parts  of  France,  2282, 
or  31  per  cent,  were  under  15  years  of  age. ^ 

If  now,  scarlet  fever  be  considered,  it  will  be  found 
that  the  disease  gets  less  fatal  to  a  very  marked 
degree  as  age  advances.      From  an  analysis  of  42,111 

^  Murchison's  Continued  Fevers,  3rd  ed.,  pp.  437  and  438. 
2  In  reckoning  the  percentage  of  admissions  at  different  ages,  the  'j']  cases 
in  which  the  age  is  not  specified  are  deducted  from  the  total. 
2  Gaultier  de  Claubry,  1849,  xiv.  29. 


MORTALITY  AT  DIFFERENT  AGES—SCARLET  FEVER  19 


cases  admitted  into  the  Metropolitan  Asylums  Board 
Hospitals,  it  will  be  seen  that  while  children  under  five 
died  at  the  rate  of  twenty  in  every  hundred  ;  the  death- 
rate  of  the  patients  over  fifteen  years  of  age  was  only 
about  4  per  cent.  The  Statistical  Committee  aptly 
remarks:^  "Such  results  are  sufficient  to  prove  how 
essential  it  is  that  every  precaution  should  be  taken  to 
prevent  the  exposure  of  young  children  to  infection, 
and  they  effectually  dispose  of  the  once  popular  notion 
among  ignorant  people  that  it  is  best  to  suffer  from  the 
disease  while  young." 

The  following  table  gives  the  admissions  of  persons 
suffering  from  scarlet  fever  at  different  ages,  and  the 
rate  of  mortality  of  42, 1 1 1  cases  admitted  into  the 
hospitals  of  the  Metropolitan  Asylums  Board  from 
1 87 1  to  1 89 1  -r — 


Ages. 

Cases 
Admitted. 

Percentage 

of  Total 
Admissions. 

Deaths. 

Mortality 

per  cent  of 

Admissions  at 

Same  Age. 

Under  5 

12,077 

28.67 

2407 

19-93 

5-10 

17,423 

41-37 

II75 

6.74 

10-15 

6,994 

16.60 

238 

3-40 

15-20 

2,859 

6.78 

95 

3-33 

20-25 

1,428 

3-39 

49 

3-43 

25-30 

661 

1.56 

27 

4.08 

30-35 

371 

.88 

21 

5.66 

35-40 

168 

•39 

1 1 

6.55 

40-45 

71 

.16 

6 

8-45 

45-50 

31 

.07 

3-23 

50-55 

21 

.04 

4-76 

55-60 

2 

.004 

50.00 

And    ) 

upwards  j 

5 

.01 

20.00 

Totals    . 

421  I  I 

4033 

9.58 

^  Report  of  Statistical  Committee,  1890,  p.  11. 


2  Ibid.  1 89 1,  p.  24. 


20  PREVENTION  OF  EPIDEMICS 

With  regard  to  diphtheria  it  will  be  seen  that  this 
disease  is  also  more  fatal  in  children  than  adults.  The 
Statistical  Committee  of  the  Metropolitan  Asylums 
Board  states,  after  analysing  3075  cases  treated  in 
their  hospitals,  that  "diphtheria,  like  scarlet  fever,  is 
most  fatal  to  infant  children.  The  maximum  mortality 
rate  is  obtained  in  the  second  year  of  life,  when  it 
reaches  the  high  percentage  of  68.79,  subsequently 
falling  with  every  additional  year  of  life  to  the  minimum 
of  1.05  per  cent  amongst  persons  between  twenty-five 
and  thirty  years  of  age."  Not  only  is  the  disease  more 
fatal  in  children  than  adults,  but  it  would  also  appear 
that  more  children,  in  proportion,  suffer  from  the 
disease,  whether  from  greater  susceptibility  or  from  a 
more  continuous  exposure  to  the  influences  under 
which  the  disease  arises.  It  cannot  be  argued  that 
adults  are  protected  by  previous  attacks  of  this  disease, 
for  one  attack  of  it  does  not  protect  a  person  from 
future  attacks. 

The  following  table  ^  gives  the  number  of  ad- 
missions of  persons  suffering  from  diphtheria  at 
different  ages,  the  percentage  of  the  total  admissions, 
the  deaths,  and  the  rate  of  mortality  in  the  hospitals  of 
the  Metropolitan  Asylums  Board  from  1888  to  1891, 
and  for  N.W.  Hospital  for  1892  : — 

1  Report  of   Statistical  Committee  of  Metropolitan  Asylums   Board,    1891. 
Figures  for  N.W.  District  Hospital  supplied  by  Dr.  Gayton,  Med.  Supt. 


MORTALITY  AT  DIFFERENT  AGES— DIPHTHERIA   21 

Number  of  Admissions  of  Persons  suffering  from  Diphtheria  at 
different  ages,  the  percentage  of  the  total  admissions,  the 
deaths,  and  the  rate  of  mortahty,  in  the  hospitals  of  the 
Metropolitan  Asylums  Board  from  1888  to  1891,  and  for 
N.W.  Hospital  for  1892. 


Ages. 

Admissions 

M.  A.  Bd. 

1888-91. 

N.W.  Dist. 

Hospital, 

Admissions 

1892. 

Total. 

Percentage 

of  Total 
Admissions. 

Deaths. 

Mortality 

per  cent  of 

Admissions  at 

Same  Age. 

Under  i 
1-2 
2-3 

3-4 
4-5 

57 

257 

335 
334 

18 

28 

47 
60 

67 

75 
201 

304 

395 
401 

2.00 

5-38 

8.14 

10.58 

10.74 

41 
130 

185 
197 
176 

54.66 
64.67 
60.85 
49-87 
43.89 

Total       ) 
under  5  j 

1156 

220 

1376 

36.86 

729 

52.97 

5-10 
10-15 
15-20 
20-25 
25-30 
30-35 
35-40 
40-45 

45-50 

50-55 
55-60 
And    ) 
upwards  j 

951 

378 

210 

163 

95 

52 

30 

20 

II 

3 

5 

I 

206 

63 
70 
43 
24 
16 

4 
8 

n 
0 
I 

I 

1157 
441 
280 
206 
119 
68 

34 
28 

13 
3 
6 

2 

30 
II 

7 
5 
3 
I 

99 
81 
50 

51 
18 
82 
91 
75 
34 
08 
16 

05 

351 

51 

12 

12 

3 

3 

2 
2 

3 
I 
I 

2 

30.33 
11.56 
4.28 
5.82 
2.52 
4.41 
5.88 
7.14 
23.07 

33-33 
16.66 

100.00 

Totals      . 

3075 

658 

3733 

1172 

31-39 

The  following  table  ^  gives  the  average  annual 
number  of  deaths  from  diphtheria  at  certain  ages  to 
every  100,000  living  at  those  ages  in  England  and 
Wales,  1861  to  1870  and  1871  to  1880: — 


1  See  Diphtheria,  by  Dr.  Thorne  Thorne,  p.  38. 


22 


PREVENTION  OF  EPIDEMICS 


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MEASLES  AND    WHOOPING   COUGH  23 

It  will  thus  be  seen  that  more  children  suffer  from 
diphtheria  than  adults,  while  at  the  same  time  it  is,  like 
scarlet  fever,  most  fatal  in  its  effects  in  children  under 
five  years  of  age. 

For  measles  and  whooping-cough  statistics  are 
meagre.  Although  these  diseases  cause  a  greater 
number  of  deaths  than  any  of  the  other  infectious 
diseases,  no  efficient  provision  has  yet  been  made  to 
prevent  them  from  spreading.  Dr.  George  Blundell 
Longstaff,  in  his  Studies  in  Statistics,  states  :  "  Measles 
causes  nearly  five  times,  and  whooping-cough  more  than 
six  times,  as  many  deaths  as  smallpox,  while  the 
amount  of  mischief  to  be  attributed  to  these  little- 
thought-of  ailments  in  the  way  of  impaired  general 
health,  permanent  lung  disease,  and  even  blindness 
and  deafness,  will  probably  never  be  known.  It  would 
appear  that  preventive  medicine  has  failed  to  control 
these  diseases.  Can  this  be  because  the  people  will 
not  co-operate  to  put  down  diseases  which  affect  only 
young  children  ?  " 

The  following  statistics  show  that,  in  the  case  of 
measles,  the  gross  mortality  is  highest  in  infancy  and 
childhood.  Of  9532  deaths  from  measles  in  London 
from  1861  to  1872,  8566  were  under  four  years  of  age, 
and  of  458  cases  treated  in  the  London  Fever  Hospital 
during  the  years  1878  to  1882,  there  were  seventeen 
deaths,  thirteen  of  which  were  of  children  under  five 
years  of  age.^  These  figures  do  not  give  the  number  of 
cases  and   deaths  at  different  ages,  and  therefore  no 

1  Collie  on  Fevers,  pp.  211  and  214. 


24  PREVENTION  OF  EPIDEMICS 

conclusion  can  be  arrived  at  in  regard  to  the  severity 
of  this  disease  at  different  periods  of  Hfe.  Nor  are 
there  any  reliable  statistics  to  show  the  susceptibility  to 
catch  the  disease  at  different  ages.  Few  authorities 
have  apparently  paid  attention  to  the  subject.  Dr. 
Thomas/  however,  states  that  "  measles  are  essentially 
dangerous  to  young  children.  Its  danger  decreases 
rapidly  with  acession  of  years,  and  in  the  late  years  of 
manhood  is  already  at  a  minimum.  In  old  people,  who 
have,  however,  but  little  predisposition  and  are  rarely 
attacked,  the  disease  is  again  dangerous."  According 
to  Passow^  the  absolute  mortality  from  measles  in 
Berlin  from  1863  to  1867  increased  up  to  the  second 
year  of  life,  at  which  point  it  reached  it  greatest  height. 
From  the  third  year  on  it  diminished,  at  first  rapidly  and 
then  slowly,  up  to  the  thirtieth  year ;  not  constantly,  how- 
ever, since  in  the  eight  and  tenth  year  there  was  a  slight 
increase,  while  from  the  twentieth  to  the  twenty-fifth 
year  no  deaths  took  place.  From  the  thirtieth  to  the 
thirty-fifth  year  the  mortality  again  increased  slightly  ; 
above  thirty -five  there  died  only  one  person  (aged 
sixty-two).  In  an  epidemic  at  the  Faroe  Islands 
in  1846,  alluded  to  by  various  authorities,  where  the 
disease  had  not  prevailed  since  1781,  and  where, 
therefore,  probably  the  whole  population  under  sixty- 
five  years  of  age  were  liable  to  suffer,  the  gross  rate  of 
mortality  for  the  first  nine  months  of  the  year  was 
nearly  three  times  more  than  the  average  in  the  first 

^  Zeimssen,  Cyclopcedia  of  the  Practice  of  Medicine,  vol.  ii.  p.  II2. 
2  Ibid.  p.  112. 


MORTALITY  AT  DIFFERENT  AGES— MEASLES       25 

year  of  life.  From  one  to  twenty  the  mortality  was 
about  the  normal,  from  twenty  to  thirty  it  was  1.4 
times  more,  from  thirty  to  forty,  2.4  times;  forty  to  fifty, 
2.6  times;  and  from  fifty  to  sixty,  4.5  times.  Passow 
reports  that  in  this  epidemic  "  not  one  old  person 
previously  unaffected  exposed  to  infection  escaped, 
although  with  some  younger  individuals  this  was  the 
case."  Copland^  states  that  the  susceptibility  pro- 
bably decreases  with  the  progress  of  age.  In  regard 
to  the  malignant  type  of  measles  Aitken  ^  is  of  opinion 
that  the  danger  is  greater  in  the  old  than  in  young 
people. 

The  following  table,  compiled  from  data  given  in 
Zeimssen's  CyclopcBclia  of  Medicine,  vol.  ii.  pp.  11 2- 11 3, 
gives  the  number  of  cases  of  measles  treated  at  Vienna 
in  1864-67,  at  Meerane  in  1861,  and  at  Frankfort 
in  1860-61,  and  the  deaths  at  various  periods  of  life. 

1  Practice  of  Medicine,  p.  813.  2  732^.  vol.  i.  p.  460. 


26 


PREVENTION  OF  EPIDEMICS 


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WHOOPING   COUGH  27 

In  the  case  of  whooping  cough  statistics  are  still 
more  meagre.  West  ^  states  that  age  exerts  an 
evident  influence  on  the  mortality  of  whooping  cough 
as  well  as  on  Its  prevalence,  both  being  greatest  in 
early  childhood.  Bristowe,^  quoting  Dr.  Smith,  states 
that  whooping  cough  Is  the  most  fatal  of  all  children's 
diseases  under  one  year  of  age,  68  per  cent,  of  all  the 
deaths  from  It  occurring  under  two  years.  According 
to  Newsholme,^  the  mortality  from  whooping  cough  is 
highest  In  the  first  year  of  life.  It  then  diminishes 
like  that  of  measles,  but  more  rapidly,  becoming  quite 
Insignificant  by  the  loth  year.  Stefi"en^  gives  West's 
tables,  and  states  that  the  younger  the  children  the 
more  dangerous  the  disease.  Fagge^  is  of  opinion 
that  when  this  disease  affects  adults  it  Is  very  dis- 
tressing, but  is  not  dangerous  nor  of  long  duration. 
I  know  myself  of  an  Island  with  a  population  of  381 
at  the  last  census,  where  no  case  of  whooping  cough 
occurred  for  twenty  years  until  1892.  On  visiting  the 
Island  in  October  of  that  year,  I  found  114  persons 
suffering  from  the  disease,  at  all  ages  up  to  20.  The 
population  being  scattered,  some  families  entirely 
escaped.  There  was  no  death.  Here  only  a  few 
cases  w^ere  very  young  children.  On  the  other  hand. 
Dr.  Russell  of  Glasgow  informs  me,  that  of  266  cases 
of  whooping  cough  treated  at  the  Belvldere  Hospital 
In    1892,   23.5   per  cent,   died,   but  he  adds  that  this 

^  Diseases  of  Infancy  and  Childhood,  p.  475. 

-   Theory  and  Practice  of  RIedicine,  f^.  148. 

^  Newsholme's  Statistics,  p.  182.  *  Zeimssen,  Cyclopcedia,  p.  717. 

^  Principles  and  Practice  of  Aledicine,  p.  1 1 38. 


28  PREVENTION  OF  EPIDEMICS 

cannot  be  taken  as  the  general  mortality,  "as  our 
patients  were  mostly  poor,  ill-nourished,  often  other- 
wise diseased  children." 

Excepting  the  fact  that  measles,  like  typhus  fever, 
is  dangerous  in  the  case  of  the  aged,  it  may  be  taken 
as  proved,  that  both  measles  and  whooping  cough 
diminish  in  severity  from  childhood  to  the  verge  of 
old  age.  If,  therefore,  the  public  would  see  the  pro- 
priety, indeed  the  duty,  of  preventing  the  "  slaughter 
of  the  innocents  "  that  is  at  present  going  on,  it  might 
be  left  to  future  generations  to  adopt  such  precautions 
as  would  protect  the  aged.  The  love  of  self-pre- 
servation would  then  make  the  aged  raise  their  voice, 
whereas  at  present  the  victims  are  dumb,  or  their  cry 
gets  no  hearing. 

In  smallpox,  the  rate  of  mortality,  as  well  as  the 
susceptibility  to  the  disease,  is  affected  rather  by  vac- 
cination than  by  age.  Of  10,403  cases  treated  by  Dr. 
Gayton  at  the  Homerton  Hospital,  2085  had  good 
vaccination  marks.  The  mortality  was  3  per  cent, 
4854  had  imperfect  vaccination  marks,  and  these  died 
at  the  rate  of  9  per  cent.  In  1295  cases  they  were 
stated  to  be  vaccinated,  but  no  vaccination  mark  was 
visible;  27  per  cent  of  these  died.  Of  2169  unvac- 
cinated  cases  43  per  cent  proved  fatal.  The  following 
table  gives  the  number  treated,  the  deaths,  and  the  rate 
of  mortality,  at  different  ages  in  the  four  classes  : — 


MORTALITY  AT  DIFFERENT  AGES—SMALLPOX     29 


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PREVENTION  OF  EPIDEMICS 


It  will  be  observed  that  in  those  "  vaccinated  with 
good  marks,"  the  number  of  very  young  children 
affected  was  small  and  the  mortality  nominal,  whereas 
in  the  unvaccinated,  under  five  years  of  age,  the  mor- 
tality and  susceptibility  were  excessive.  On  the  other 
hand,  while  the  susceptibility  shows  considerable 
diminution  between  the  ages  of  ten  and  fifteen,  the 
mortality  during  this  period  was  not  only  much  less 
than  among  the  infants,  but  even  less  than  at  any 
subsequent  period  of  life. 

It  will  thus  be  seen  that  in  the  case  of  all  the 
infectious  diseases  prevalent^  in  this  country,  adults 
are  less  liable  to  catch  them  than  children,  and,  with 
the  single  exception  of  typhus  fever,  that  these  diseases 
are  most  fatal  during  infancy  and  childhood.  The 
prevention  of  infectious  diseases  would  therefore  not 
cause  the  population  to  suffer  from  more  extensive  or 
more  severe  epidemics  (although  at  rarer  intervals)  in 
the  future.  On  the  contrary,  the  extension  of  isolated 
outbreaks  into  epidemics  would  be  prevented  with  the 
same  ease  as  isolated  outbreaks  of  typhus  fever  are 
prevented  from  spreading  into  general  epidemics  at 
the  present  day.  Not  so  long  ago,  typhus  fever  pre- 
vailed over  the  whole  country,  and  consequently  the 
resources  existing  were  not  able  to  cope  with  it.  Now, 
if  an  outbreak  occurs  in  any  locality,  it  is  immediately 
suppressed.  This  disease  now  breaks  out  only  at 
comparatively  rare  intervals  in  isolated  localities,  and 

1  Smallpox,  because  of  the  protective  influence  of  vaccination,  can  hardly  be 
said  to  be  prevalent  in  this  country  now. 


PROGRESS  MADE  31 


local  authorities  with  the  means  at  their  disposal  are 
able  to  check  its  spread.  If  the  other  infectious 
diseases  were,  by  means  of  Isolation  Hospitals  and 
other  measures,  once  got  under  control,  and  the  popu- 
lation protected  in  the  early  years  of  life,  a  larger 
number  would,  no  doubt,  be  liable  to  suffer,  as  they 
would  not  be  protected  by  a  previous  attack,  exactly  in 
the  same  way  as  the  whole  population  is,  at  the  present 
day,  liable  to  suffer  from  typhus  fever.  This,  how- 
ever, would  be  more  than  compensated  for  by  the 
fewer  outbreaks  that  would  occur,  and  by  the  greater 
resources  and  increased  facilities  for  dealing  effectually 
with  them.  Although  a  higher  proportion  of  the 
population  would  be  liable  to  suffer,  outbreaks  would 
be  rarer  and  could  be  more  easily  kept  under  control. 
Even  if  such  outbreaks  did  occur,  the  diseases  would 
not  have  the  same  tendency  to  spread  with  rapidity 
among  persons  at  all  ages  as  they  have  among  children, 
and  fewer  would  die.  I  have  already  shown  that  the 
susceptibility  to  suffer  from  these  diseases  gets  less  as 
age  advances,  and,  with  the  exception  of  typhus  and 
typhoid  fevers,  the  rate  of  mortality  also  decreases. 

Even  with  the  imperfect  means  hitherto  provided 
for  preventing  the  spread  of  infection,  considerable 
progress  has  been  made.  In  the  case  of  typhus  fever, 
there  has  been  an  almost  continuous  decrease  in  the 
number  of  deaths  in  England  and  Wales  for  the  past 
twenty-four  years.  The  number  of  deaths  from  that 
disease  fell  from  4281  in  1869  to  318  in  1885.  During 
the  same  period,  the  number  of  deaths  from  typhoid 


PREVENTION  OF  EPIDEMICS 


and  simple  continued  fevers  decreased  from  13,967 
in  1869,  to  an  average  of  8657  per  annum,  during  the 
five  years  1876-80,  and  6671  per  annum  from  1881  to 
1885,  and  this  notwithstanding  the  increase  of  the 
population.  The  deaths  from  scarlet  fever,  at  all  ages 
during  1851-60,  amounted  to  88  per  100,000  of  the 
population  In  England  and  Wales.  From  1861-70  the 
rate  rose  to  97.  From  1871-80  only  72  per  100,000 
died.  Since  1878  the  rate  fell  continuously  until  1886, 
when  it  was  only  17  per  100,000.  From  1838-42 
the  number  of  deaths  from  smallpox  was  57.2  per 
100,000,  from  1865-69  it  fell  to  14.4.  From  1870-74 
it  rose  to  42.7  per  100,000,  but  fell  from  1875-79  to  8*3, 
and  from  1880-84  to  6*5  per  100,000.^  If  energetic 
measures  were  carried  out,  and  efficient  means  pro- 
vided by  local  authorities  for  the  purpose,  this  progress 
would  proceed  at  an  accelerated  rate  until  the  infectious 
diseases  most  prevalent  amongst  us  would  be  as  rarely 
met  with  as  spotted  typhus,  or  the  black  plague,  which 
at  one  time  decimated  the  population. 

1  Progress  of  Preventive  Medicine  during  the  Vict07-ian  Era,  by  Dr.  Thorne 
Thorne. 


CHAPTER   III 

The  Gain  to  the  Community  through  the  Adoption  of  Effec- 
tive Measures  against  the  Spread  of  Infection 


0' 


In  Scotland  the  population  in  1881  was  3,735,57 
and  in  1891,  4,025,647.  As  may  be  seen  from  the 
table  on  the  following  page,  the  number  of  deaths 
from  the  most  common  of  the  zymotic  diseases 
during  the  10  years  was  77,780,  giving  an  average 
of  yy/S  per  annum. 

The  economical  loss  to  the  community  by  this 
item  alone  is  very  large.  Dr.  Farr  has  shown  that 
each  individual  member  of  the  community  has  an 
actual  money  value  represented  by  the  wages  he  is 
capable  of  earning,  and  that  this  constitutes  the  most 
important  factor  in  the  wealth  of  the  community. 
Deducting  the  amount  required  for  subsistence,  ^150 
is  the  mean  nett  value  of  each  member  of  the  male 
population,  estimated  by  the  standard  of  the  agri- 
cultural labourer.  This  amount  is  obtained  by 
capitalising  the  income  derived  from  wages  and 
deducting  all  the  expenses  of  subsistence.  It  is 
evident  that  the  value   will  vary  greatly  at   different 


D 


34 


PREVENTION  OF  EPIDEMICS 


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MORTALITY  IN  SCOTLAND  35 

ages,  being  partly  dependent  on  the  expectation  of 
life,  and  very  low  in  infancy  on  account  of  the  large 
death-rate  under  5  years  of  age. 

On  Dr.  Farr's  basis  the  child  of  an  agricultural 
labourer  is  worth  only  ^5  at  birth,  ^56  at  the  age 
of  five,  ^117  at  the  age  of  ten,  ^192  at  the  age  of 
fifteen,  increasing  to  ^246  at  the  age  of  twenty-five, 
then  steadily  declining  to  only  £\  at  the  age  of 
seventy,  while  at  eighty  the  cost  of  future  maintenance 
is  greater  than  the  earnings  by  £^1.^ 

The  ']^^'^  deaths  per  annum  in  Scotland  from 
zymotic  diseases  occurred  at  various  ages.  If,  how- 
ever, the  half  of  that  number  be  taken  as  males  and 
multiplied  by  ^150  (the  mean  value  of  each  member 
of  the  male  population),  the  economical  loss  to  the 
community  will  be  found  to  amount  to  a  considerable 
sum.  "A  still  greater  economical  loss  to  the  com- 
munity is  caused  by  the  preventible  sickness  and 
mortality  from  fifteen  to  forty -five  years  of  age. 
Trusting  to  Farr's  English  Life  Tables,  of  1,000,000 
children  born,  72,397  die  between  the  ages  of  fifteen 
and  forty-five."".  .  .  "  Premature  death  is  an  evil  and 
a  loss  to  the  state,  but  sickness  is,  from  an  economical 
aspect,  a    still    greater    evil  ;    for    sickness     adds    an 

^  Newsholme's  Vital  Statistics,  p.  14. 

2  By  them  [infectious  diseases]  and  by  other  causes,  out  of  1000  children 
born  in  Liverpool,  5 1 8  were  destroyed  in  the  first  ten  years  of  their  life,  some  by 
smallpox,  many  by  measles,  scarlet  fever,  whooping-cough,  typhus  and  enteric 
fever.  Out  of  1000  children  born  in  London,  351  die  under  ten  years  of  age 
by  zymotic  diseases  and  other  causes.  In  the  healthy  districts  of  England,  out 
of  1000  children  born,  205  die  in  the  first  ten  years  of  life. — Farr's  Statistics, 
P-  327- 


36  PREVENTION  OF  EPIDEMICS 

additional  burden,  while  death  can  but  remove  the 
bread  winner."  ^ 

The  7778  deaths  per  annum  is  therefore  far  from 
representing  all  the  loss.  Every  death  represents  a 
group  of  cases  which  had  suffered  from  the  disease, 
but  had  recovered  completely  or  partially.  The  number 
that  recover  from  the  various  infectious  diseases  varies 
not  only  according  to  the  disease,  but  also  according 
to  the  age  and  social  position  of  the  sufferer,  as  well  as 
the  type  of  the  special  disease  and  other  conditions. 
In  the  hospitals  of  the  Metropolitan  Asylums  District 
Board,  during  a  period  of  twenty  years,  42, 1 1 1  cases 
of  scarlet  fever  were  admitted;  of  these  4033  died, 
being  at  the  rate  of  9.5  per  cent.  Of  3733  cases  of 
diphtheria  admitted  into  the  same  hospitals,  11 72 
died,  giving  a  mortality  of  31.3  per  cent.  Of  6960 
cases  of  typhoid  fever,  1232  died,  being  at  the  rate 
of  17.7  per  cent,  and  of  2 121  cases  of  typhus  fever, 
432  died,  giving  a  mortality  of  20.3  per  cent.  The 
rate  of  mortality  in  57,037  cases  of  smallpox  during 
the  same  period  was  17.3  per  cent. 

If  persons  suffering  from  these  diseases  died  at 
the  same  rate  in  Scotland  during  the  past  ten  years, 
it  will  be  seen  that  each  of  the  7778  deaths  from 
infectious  disease  represents  a  group  of  persons, 
varying  in  number  according  to  the  disease,  who  had 
suffered  but  survived.  Every  death  from  scarlet 
fever  would  represent  about  ten  cases,  from  diphtheria 
about  three  cases,  from  typhoid  fever  about  six  cases, 

1  Nevvsholme's  Vital  Statistics,  p.  279. 


ECONOMIC  LOSS  FROM  EPIDEMICS  37 

from  typhus  about  five,  and  from  smallpox  about  six 
cases. 

The  148  deaths  from  smallpox  during  the  ten 
years  would  represent  about  888  cases  of  that  disease, 
or  about  eighty-eight  cases  per  annum.  The  12,537 
deaths  from  scarlet  fever  would  represent  125,370 
cases,  or  about  12,537  cases  per  annum.  The  8108 
deaths  from  diphtheria  would  represent  24,324  cases 
of  that  disease,  or  about  2432  cases  yearly,  and  the 
9533  deaths  from  typhoid  fever  during  the  ten  years 
would  represent  57,198  cases  of  that  disease,  or  about 
5719  per  annum. 

The  loss  incurred,  even  by  the  simple  interference 
with  labour,  through  this  enormous  amount  of  sickness 
can  scarcely  be  computed,  "  and  the  consequences 
which  are  left  behind  (in  the  survivors)  in  the  loss  of 
health,  activity,  sight,  hearing,  and  other  faculties  which 
render  life  happy  and  useful,  are  lamentable."  ^ 

After  taking  the  evidence  of  the  highest  authorities, 
the  Fever  and  Smallpox  Hospital  Commission  re- 
ported that  the  period  of  seclusion  in  cases  of  fever 
lasts  on  an  average  eight  weeks,  and  in  smallpox  six. 
In  an  average-sized  house  and  family  it  has  been  found 
to  be  impracticable  to  Isolate  a  person  suffering  from 
fever  or  smallpox  effectually  from  the  rest  of  the 
inmates.  The  result  is  that  all  susceptible  persons 
living  in  such  houses  are  liable  to  catch  the  disease  if 
one  of  the  members  contracts  infection.  On  many 
occasions  it  is  also  impossible  to  prevent  the  inmates 

^  Report  of  Fever  and  Smallpox  Hospitals  Commission,  p.  29. 


38  PREVENTION  OF  EPIDEMICS 

from  mixing  with  others  and  carrying  infection  to 
them.  It  is  also  found  to  be  a  great  hardship  to  many 
a  business  or  working  man  to  have  to  give  up  work 
and  lose  his  wages  at  the  very  time  his  family  is  ill, 
and  when  he  has  to  incur  extra  expenses  for  medical 
attendance,  medicine,  and  food.  When  a  case  of 
infectious  disease  occurs  in  a  house,  all  the  inmates 
are,  as  a  rule,  not  immediately  attacked.  Another 
catches  the  disease  from  the  first  case  within  a  few 
days  of  the  commencement  of  the  outbreak.  The 
second  case,  however,  will  not  fall  ill  at  once.  The 
number  of  days  varies.  Perhaps,. as  a  rule,  it  would  be 
safe  to  reckon  it  from  nine  to  fourteen  days.  Other 
members  of  the  family  may  escape  longer,  and  some 
may  not  suffer  at  all.  Taking  the  average  length  of 
time  a  person  should  be  secluded  or  isolated  from  the 
public  as  eight  weeks,  it  will  be  seen  that  even  with 
two  cases  of  infectious  disease  in  a  family,  it  will  take 
about  ten  weeks  before  the  house  and  clothing  can  be 
disinfected  and  the  inmates  allowed  to  mix  with  safety 
with  others.  If  even  one  member  of  the  family,  with 
wages  of  2s.  6d.  per  working  day,  were  kept  from 
work,  either  through  illness  or  from  the  risk  of  spread- 
ing infection,  the  loss  amounts  to  £']  :  los.  Every 
family  in  the  community  runs  more  or  less  the  same 
risk  of  being  infected  by  fevers  and  incurring  this  loss, 
although  the  full  loss  would  only  be  felt  when  an  adult 
male  was  disabled  or  prevented  from  earning  his 
wages.  This  loss  falls  in  full  force  on  the  poorest  of 
the  population,  the  very  class  least  able  to  stand  the 


COMPULSORY  RATES  A    GOOD  INVESTMENT        39 

Strain.  Supposing  now  that  an  hospital  were  provided, 
the  first  case  in  the  family  immediately  removed,  and 
the  house  furniture  and  clothing  properly  disinfected, 
the  house  and  family,  instead  of  being  a  menace  to  the 
neighbourhood  for  months,  would  be  rendered  perfectly 
harmless,  and  the  well-being  of  the  family  would  be 
interfered  with  to  the  least  possible  extent.  They 
would  be  able  to  attend  to  their  work,  and  the 
chance  of  others  catching  the  disease  would  be 
lessened  to  the  minimum.  Supposing  the  valuation 
of  an  area  provided  with  a  small  isolation  hospital 
is  ^82,000,  and  supposing  the  erection  of  such  a 
hospital  would  cost  a  sum  of  ^2000,  a  little  cal- 
culation will  show  that  that  amount  might  be  paid 
back  in  thirty  years'  instalments,  with  interest  at  3|- 
per  cent,  at  a  cost  to  the  ratepayers  of  about  one 
farthing  and  a  half  in  the  pound.  This  small  rate 
would  afford  means  whereby  misery,  hardship,  and 
death  would  be  prevented  among  all  classes  of  the 
population,  greater  security  would  be  given  against 
the  spread  of  infection,  poverty  and  pauperism  would 
be  lessened,  and  school  attendance  improved.  The 
population  would  gain  more  by  the  saving  in  doctors' 
fees,  in  other  losses  and  expenses  incidental  to  sick- 
ness and  death  from  infectious  diseases,  and  in  the 
decrease  of  poor  rates,  than  they  would  lose  by  their 
small  contribution  towards  the  building,  upkeep,  and 
maintainance  of  an  isolation  hospital.  The  yearly 
charge  would  be  exceedingly  small  in  proportion  to  the 
benefit   that  would  accrue   from   such   an   institution. 


40  PREVENTION  OF  EPIDEMICS 

I  do  not  know  of  any  more  profitable  investment. 
Money  invested  in  an  Isolation  Hospital  and  charged 
on  the  rates  may  be  compared  to  voluntary  contri- 
butions to  a  society  to  provide  against  sickness  or 
accidents.  Members  of  a  Local  Authority,  such  as 
Burgh  Commissioners,  County  Councillors,  or  mem- 
bers of  Local  Boards,  may  be  compared  to  the  directors 
of  such  a  society.  They  are  elected  by  the  public  to 
take  all  necessary  precautions  against  disease  and  ill- 
health,  and  they  are  invested  by  statute  with  authority 
to  borrow  money  and  levy  rates  to  meet  the  necessary 
expenditure. 

Into  the  commodious,  secluded,  and  well-appointed 
mansions  of  the  rich,  infectious  disease  does  not  so 
easily  find  its  way,  and  even  when  it  does  it  may  be 
possible  to  isolate  a  case  so  as  to  be  of  very  little 
danger  to  the  other  inmates,  and  to  enable  them  to 
mix  with  their  neighbours  and  attend  to  their  voca- 
tions with  little  or  no  risk  of  spreading  the  disease. 
The  following  (and  it  is  only  one  of  many  cases  which 
might  be  quoted)  illustrates  one  of  the  many  ways 
by  which  infectious  disease  may  spread,  and  shows 
how  important  it  is  for  the  well-to-do,  even  for  their 
own  personal  safety,  to  do  their  utmost  to  provide 
proper  means  for  the  isolation  and  safe  management 
of  cases  of  infectious  disease.  Deputy  Surgeon- 
General  Bostock,  a  member  of  the  Metropolitan 
Asylums  Board,  stated  before  the  Fever  and  Small- 
pox Hospitals  Commission  :  "  A  very  remarkable  case 
occurred  two  or  three  days  ago  which  will  illustrate 


DANGERS   TO    THE  RICH  41 

what  I  say.  Six  children  were  admitted  on  Saturday 
night  to  the  Hospital  at  Stockwell  [suffering  from 
smallpox].  They  all  belonged  to  one  family  and 
lived  in  a  small  apartment  at  the  top  of  the  Hay- 
market.  Their  father  is  a  tailor  working  for  a  first- 
rate  firm  in  the  West  End  of  London ;  and  about 
three  weeks  ago  one  of  his  sons  (there  were  nine  of 
them  altogether)  had  smallpox,  which  was  treated  at 
home  and  was  not  notified.  .  .  . — The  father  was  a 
tailor,  you  say  }  Yes,  in  the  employ  of  a  fashionable 
tailor  in  the  West  End  of  London,  and  in  addition  to 
this,  underneath  was  a  laundry  employing  five  women 
who  came  every  day,  where  washing  was  taken  in 
from  the  neighbouring  families." 

The   following    is    recorded     by    the    Hon.    Rollo 
Russell :  ^ — "  A    school    teacher    returned  home  from 
another  place  with  diphtheria.     Within  the  next  six 
months  cases  occurred  among  her  family  and  relations. 
It    entered    the    house    of  the    family  physician,   and 
several  deaths   occurred.      He  left  the  town   and   his 
house  was  vacant  for  some  months.      People  went  to 
and  from  the  infected  houses  to  the  post-office,  which 
was  also  a  grocer's  shop,  and  the  grocer  visited  the 
houses    with    the   groceries.       His    family    was    next 
attacked  and  broken  up,  and  its  members  scattered. 
A  new  physician  came  to   occupy  the  vacant  house. 
Soon    after   moving   his   children  were    attacked.     A 
lying  -  in   woman  whom  he  attended  and  her  boy  of 
seven    were    both    attacked  ;    then    a  neighbour  who 

^  Epidemics^  Plagues,  and  Fevers,  p.  138. 


42  PREVENTION  OF  EPIDEMICS 

called  on  this  woman  ;  and  so  the  disease  extended 
for  eiofhteen  months." 

Isolation  hospitals  do  not  at  once  ensure  the  total 
absence  of  infectious  disease.  If  universally  adopted, 
however,  and  full  advantage  were  taken  of  them, 
this  desirable  result  would  reach  towards  completion 
in  the  future,  and  disease  from  infection  would  get 
rare  indeed.  Side  by  side  with  Isolation  Hospitals, 
other  measures,  such  as  disinfection  of  clothing  and 
premises,  would  have  to  be  practised,  and  the  sources 
from  which  infection  springs  would  be  discovered  and 
extirpated  one  by  one. 

Infectious  diseases  of  various  kinds  prevailed  in 
this  country  for  generations,  probably  since  man  first 
inhabited  the  British  Isles.  The  materies  morbi  or 
the  "thing  that  infects,"  or  by  means  of  which  disease 
is  transmitted  from  one  person  to  another,  is  very 
tenacious  of  life,  and  maintains  its  power  of  infection 
under  certain  conditions  outside  the  human  body  for  a 
long  time.  It  adheres  to  clothes,  it  lodges  in  cracks 
and  crevices,  or  on  inequalities  of  house  walls,  and  some 
kinds  live  in  insanitary  drains  and  cesspools.  Even 
if  every  precaution  be  taken  by  means  of  isolation  and 
disinfection  for  preventing  such  diseases  from  spreading 
from  person  to  person,  it  is  evident  that  for  a  long 
time  occasional  outbreaks  will  occur,  if  the  infecting 
material  of  any  particular  disease  is  disturbed  where 
it  now  lies  dormant,  and  if  it  finds  its  way  into  the 
human  system.  By  isolation  and  disinfection,  new 
centres  or  premises  will  be  prevented  from  becoming 


CENTRES   OF  INFECTION  43 

infected.  The  sources  or  infected  premises  from  which 
epidemics  of  some  diseases  now  spring  will,  through 
the  inquiries  and  investigations  of  health  officers,  be 
detected  and  disinfected,  and  outbreaks  of  such  diseases 
will  get  gradually  rare  in  proportion.  There  will 
therefore  ultimately  be  no  pecuniary  loss  to  the 
community  in  being  rated  for  hospitals,  while  the 
benefit  to  future  generations  will  be  incalculable. 

By  the  aid  of  Isolation  Hospitals,  the  enforcement 
of  the  provisions  of  the  Public  Health  and  the 
Infectious  Disease  Notification  Acts,  with  ordinary 
care  and  vigilance  on  the  part  of  the  medical  officers  of 
health  and  sanitary  inspectors,  infectious  diseases  may 
in  time  be  almost  entirely  blotted  out  of  rural  districts. 
In  the  ordinary  discharge  of  their  duties,  houses 
and  localities  where  such  diseases  formerly  existed, 
and  from  which  they  may  again  spread,  will  be 
gradually  discovered,  and  precautions  taken  to  prevent 
such  a  catastrophe.  I  have  myself  discovered  several 
localities  and  houses  where  typhoid  fever  and  diph- 
theria broke  out  time  after  time.  If  such  places  are 
disinfected  and  existing  sanitary  defects  remedied, 
outbreaks  of  infectious  disease  will  not  again  originate 
in  them.  Without  hospitals,  how^ever,  new  centres 
from  which  such  diseases  may  spread,  multiply  in 
spite  of  every  precaution  that  can  be  taken. 

The  following  case  illustrates  this  :  A  girl  from  one 
parish  was  at  service  in  a  farmhouse  about  ten  miles 
from  her  home.  She  took  ill  in  the  house  of  her 
employer,  and  was  sent  home  to  her  father's  house. 


44  PREVENTION  OF  EPIDEMICS 

The  case  was  notified  to  me  as  typhoid  fever  on  7th 
September  1892.  On  inquiry  I  found  that  typhoid  fever 
had  broken  out  several  times  during  the  past  few  years 
in  the  same  farmhouse  in  which  this  case  originated. 
One  death  was  registered  from  typhoid  fever  at  a 
neighbouring  cottar's  house  in  October  1889,  where 
several  persons  suffered  from  the  disease.  This  out- 
break was  traced  to  the  same  farmhouse.  In  January 
1890  some  persons  in  the  farmhouse  are  reported  to 
have  suffered  from  some  disease  resembling  fever,  but 
its  nature  was  not  known.  In  the  autumn  of  the  same 
year  five  persons  in  another  neighbouring  cottar's 
family  are  reported  to  have  suffered  from  typhoid 
fever.  A  member  of  this  family  had  also  been  at 
service  in  the  same  farmhouse  and  was  sent  home 
ill  with  t3/phoid  fever.  The  sanitary  inspector  found 
the  drainage  defective,  the  house  infested  with  rats, 
and  an  outhouse  at  the  back  on  a  higher  level  and 
draining  towards  the  farmhouse. 

The  excretions  in  typhoid  fever  contain  the  agent 
of  infection,  probably  in  the  most  concentrated  condition. 
If  these  are  thrown  out  into  old  stone-built  drains,  without 
the  most  thorough  disinfection  the  organism  of  infection 
will  lodge  and  thrive  in  the  filth  along  the  course  of 
the  sewer.  In  the  same  manner  soil  saturated  with 
organic  matter  about  insanitary  dwellings  may  harbour 
infection  independent  of  its  position.  Lodged  in  some 
positions  the  infection  may  remain  harmless  for  years. 
If,  however,  by  any  chance  infected  particles  of  filth 
get  mixed  with  water,   or  milk,  or  food,  and  thereby 


CENTRES   OF  INFECTION  45 

find  their  way  into  the  system,  the  disease  is  again 
produced,  and  perhaps  in  a  more  virulent  form. 

It  is  probable  that  some  of  the  numerous  epidemics 
of  typhoid  fever  which  have  been  traced  to  the  milk 
supply  in  the  various  large  towns  arose  from  similar 
centres. 

The  persons  that  contracted  the  fever  in  the 
above-mentioned  farmhouse  were  treated  at  their 
homes  in  old  insanitary  dwellings,  instead  of  being 
isolated  in  a  hospital.  These  dwellings  may  in 
future  act  as  centres  for  other  outbreaks.  Isola- 
tion Hospitals  would,  therefore,  tend  to  prevent  the 
multiplication  of  infected  centres,  as  well  as  check 
the  immediate  spread  of  such  diseases.  Of  all 
diseases  cholera  is  probably  the  most  dangerous  in 
this  respect.  The  comjna  bacilhts  or  infecting  agent 
of  that  disease  appears  to  live  and  multiply  in  soil  or 
water.  Wherever  the  disease  is  likely  to  break  out, 
Isolation  Hospitals  should  be  provided  to  prevent  it 
from  spreading.  The  immediate  isolation  of  the  first 
case  or  cases  that  appear,  the  thorough  disinfection  or 
destruction  of  excretions,  and  of  all  infected  articles 
and  premises,  are  absolutely  necessary.  If  cases  are 
treated  at  their  own  homes,  the  soil  in  and  about  the 
houses  is  bound  to  get  more  or  less  infected,  wind 
blows  about  the  infected  dust,  or  water  gets  infected 
by  the  soakage  and  drainage  of  the  infected  soil. 
Every  house  in  which  a  case  is  treated  becomes  an 
additional  source  of  danger,  and  a  centre  from  which 
the  disease  may  spread. 


46  PREVENTION  OF  EPIDEMICS 

That  hospital  provision  is  the  most  effective  means 
at  present  known  to  prevent  the  spread  of  infection 
may  be  taken  as  proved  beyond  doubt.  A  Httle  con- 
sideration will  at  once  show  this.  A  large  proportion 
of  the  population  live  in  one  or  two-roomed  dwellings, 
and  in  such  dwellings  it  may  be  taken  as  impossible  to 
isolate  the  sick  from  the  healthy. 

In  Aberdeenshire,  of  60,551  families,  8250  families 
live  in  houses  of  one  apartment,  and  19,891  in  houses 
of  two  rooms. 

In  Forfarshire,  of  64,795  families,  13,820  families 
live  in  one-roomed,  and  28,936  in  two-roomed  dwell- 
ings. 

In  Ayrshire,  of  46,874  families,  12,143  families  live 
in  houses  of  one  room,  and  18,427  families  in  houses 
of  two  rooms. 

In  Lanarkshire,  of  231,633  families,  74,389  live  in 
one-roomed,  and  98,126  in  two-roomed  houses.  The 
figures  in  all  these  counties  include  large  towns. 

In  Inverness-shire,  which  is  mainly  rural,  of  18,856 
families,  2818  families  live  in  houses  of  one  room,  and 
7192  in  houses  of  two  rooms. 

In  Argyllshire,  of  17,442  families,  2502  live  in 
one-roomed,  and  6125  families  lived  in  two-roomed 
dwellings. 

In  the  rural  parts  of  Scotland  as  a  whole,  at  the 
last  census  (1891),  46,371  families  lived  in  houses  of 
one  apartment,  109,159  families  in  houses  of  two,  and 
53,125  families  in  houses  of  three  apartments. 

The   mean   number  of  persons   in   each  family  in 


HARDSHIP    TO    THE  POOR  47 

Scotland  in  (1891)  was  4.5,  and  the  number  of  persons 
to  a  house  in  the  rural  districts  was  5.05. 

One  may  take  it  as  a  rule  that  houses  of  three 
apartments  and  under,  more  particularly  in  rural 
districts,  are  small,  badly  built,  drained,  and  ventilated. 

When  infectious  disease  breaks  out  in  a  family 
living  in  such  a  house,  it  is  practically  impossible  to 
prevent  the  rest  of  the  family  from  getting  it,  unless 
the  first  case  is  removed  to  a  hospital. 

The  following  cases,  recorded  by  Drs.  Barker  and 
Cheyne,  in  their  Treatise  on  Fevers,  illustrate  what  is 
liable  to  happen  in  the  absence  of  an  Isolation  Hospital : — 

"  Previous  to  the  opening  of  the  hospital  many 
instances  of  extreme  misery  occurred.  I  would  par- 
ticularise the  following : — E.  F.,  a  young  woman 
whose  husband  was  obliged,  in  order  to  seek  employ- 
ment, to  leave  her  almost  destitute  with  three  children 
in  a  miserable  cabin,  was  induced  one  night  to  give 
the  shelter  of  her  roof  to  a  poor  beggar,  who  it 
appears  had  fever.  The  consequence  was  that  she 
caught  the  disease,  and  from  the  terror  and  alarm 
created  in  the  neighbourhood,  was,  with  her  three 
children,  deserted,  except  that  some  persons  left  a  little 
water  and  milk  in  the  window  for  the  children  :  one 
about  four,  the  other  three,  and  the  third  an  infant  at 
the  breast.  In  this  way  she  continued  for  a  week, 
when  a  neighbour  heard  of  her  distress  and  sent  her 
a  loaf  of  bread,  which  was  left  in  the  window.  Four 
days  after  this  he  grew  uneasy  about  her,  and  one 
night  he  prepared  some  tea  and  bread,  and  taking  a 


PREVENTION  OF  EPIDEMICS 


female  servant  with  him,  set  off  to  her  relief  When 
he  arrived  the  following  scene  presented  itself.  In 
the  window  lay  the  loaf,  where  it  had  been  deposited 
four  days  previously ;  in  one  corner  of  the  cabin,  on 
a  little  straw,  without  covering  of  any  kind,  lay  the 
wretched  mother  actually  dying,  and  her  infant  dead 
by  her  side,  for  want  of  that  sustenance  which  she 
had  not  to  give.  On  the  floor  lay  two  children,  to 
appearance  also  dying  of  cold  and  hunger.  At  first 
they  refused  to  take  anything,  and  he  had  to  force  a 
little  liquid  down  their  throat,  and  in  a  short  time  they 
revived,  and  with  the  cautious  administration  of  food, 
recovered  the  effect  of  their  suffering.  The  mother 
expired  before  the  visitor  quitted  the  room,  who,  I 
am  happy  to  add,  did  not  suffer  for  his  humanity."^ 

"  Mr.  and  Mrs.  L.  kept  a  boarding-school  for  young 
ladies,  and  a  preparatory  school  for  boys,  and  Mr.  L. 
attended  private  pupils.  They  had  nine  children,  the 
elder  of  whom  were  capable  of  assisting  in  the  school. 
Having  maintained  an  irreproachable  character,  they 
had  every  reason  to  hope  that  their  exertions  would 
enable  them  to  support  their  family  in  comfort.  But 
their  hopes  have  been  blighted.  A  servant  who  had 
the  prevailing  fever  introduced  the  infection  into  the 
family  in  January  i8 — ,  and  during  nine  months,  not- 
withstanding all  the  precautions  that  were  taken,  the 
fever  has  occurred  at  different  periods,  during  which 
time  the  nine  children,  four  of  the  boarders,  two  ser- 
vants,  and  last  of  all,    Mr.   L.   himself, — in  all  sixteen 

1  Barker  and  Cheyne  on  Fevers,  vol.  i.  pp.  65  and  66. 


HARDSHIP   TO    THE  POOR  49 

persons, — have  been  attacked.  .  .  .  The  consequence 
has  been  that  the  pupils  have  been  removed,  and  the 
private  tuition  has  been  discontinued,  that  debts  have 
been  incurred  to  support  Hfe,  and  all  the  means  of  pay- 
ing them  have  been  cut  off,  .  .  .  and  a  length  of  time 
must  elapse  after  his  own  recovery  before  he  can 
resume  private  tuition  lest  he  should  be  instrumental 
in  bringing  upon  other  families  that  scourge  by  which 
he  has  so  much  suffered,"  ^ 

Only  two  years  ago  typhus  fever  broke  out  in  an 
isolated  township  on  an  island  on  the  West  Coast  of 
Scotland.  Like  many  other  places  the  Local  Authority 
had  not,  and  still  have  not,  made  provision  for  the 
isolation  of  cases  of  infectious  disease.  The  fever 
spread,  and  several  persons  died,  among  them  an  old 
man  who  had  volunteered  to  nurse  a  case  of  typhus. 
By  this  time  the  population  got  alarmed.  No  one  could 
be  got  to  coffin  the  body  until  an  old  pedlar  volun- 
teered to  assist  the  widow.  After  this  the  widow  and 
her  granddaughter  were  shunned,  and  no  one  would 
admit  the  pedlar  into  his  house  for  fear  of  infection. 
They  tried  to  leave  the  district  by  steamer,  but 
being  infected  they  were  refused.  The  next  port 
was  about  thirty  miles  away,  and  there  they  thought 
they  would  not  be  known.  The  panic,  however, 
spread,  and  the  news  preceded  them.  They  could 
not  get  a  hire,  and  so  they  had  to  walk.  Although  it 
was  winter,  with  showers  of  snow,  they  were  refused 
shelter  on  the  way.     When  tired,  they  had  to  sleep  on 

^  Barker  and  Cheyne  on  Fevers,  vol.  i.  p.  67. 
E 


50  PREVENTION  OF  EPIDEMICS 

the  roadside.  When  within  eight  miles  of  the  har- 
bour the  old  man  lay  down  exhausted.  The  widow 
and  her  grandchild  trudged  along  and  reached  the 
port.  They  were  allowed  to  sleep  under  an  old  boat 
until  a  steamer  arrived,  and  they  went  to  Glasgow, 
where  both  suffered  from  typhus  fever. 

The  pedlar  was  found  dead  by  the  roadside,  so 
that  the  brave  spirit  of  humanity  which  the  poor  old 
fellow  had  shown  alone  amid  his  neighbours  cost  him 
his  life. 

On  the  other  hand,  in  his  evidence  before  the 
Infectious  Hospitals  Commission,  Dr.  Dudfield,^  medi- 
cal officer  of  health  for  Kensington,  stated  :  "  If  we 
hear  of  a  case  pretty  quickly,  and  it  is  removed,  we 
reckon  to  have  done  with  that  house ;  we  hear  no 
more  of  the  disease  there." 

Dr.  Thorne^  stated  :  "  In  the  Alcester  Rural  Dis- 
trict in  Warwickshire,  I  found  that  the  early  removal 
of  cases  of  scarlet  fever  from  houses  which  contained 
children  who  were  unprotected  by  having  had  previous 
attacks,  had  prevented  any  spread  of  infection.  For 
example,  in  three  instances  the  first  pupil  attacked  had 
been  removed  from  school,  and  in  each  of  these  cases 
no  spread  took  place ;  whereas  on  another  occasion, 
when  scarlet  fever  attacked  a  pupil  at  a  school,  and  it 
was  attempted  to  treat  it  in  isolation  in  the  school 
building,  the  disease  spread,  and  seven  other  attacks 
followed  in  the  schoolhouse." 


1  Smallpox  and  Fever  Hospitals  Commission,  Minutes  of  Evidence,  Question 
1596.  ^  Ibid.,  Question  1129. 


INFLUENCE   OF  ISOLATION  HOSPITALS  51 

Dr.  Collier,^  medical  officer  of  health  for  Fulham, 
remarked  :  "No  doubt  70  per  cent  of  the  cases  that 
occur,  and  I  say  this  after  the  most  serious  reflection, 
could  be  prevented,  if  every  case  was  disclosed.  In 
my  reports  published  last  year,  I  have  shown  that 
where  cases  of  smallpox  have  been  immediately 
reported,  and  the  patients  immediately  removed,  not 
a  single  person  has  caught  the  disease  at  the  same 
house,  whereas  in  houses  where  the  patients  have  not 
been  removed  other  cases  have  occurred." 

Dr.  Browning,^  medical  officer  for  Rotherhithe, 
stated,  after  detailing  a  case  :  "  Here  was  a  case  of  a 
well-to-do  tradesman,  a  boot  and  shoemaker,  a  hot- 
headed anti-vaccinationist,  who  lost  his  wife  and  three 
children  in  succession,  by  the  most  aggravated  form  of 
smallpox,  who  persisted  in  refusing  to  allow  the  others 
in  the  house  to  be  revaccinated,  and  refused  to  allow 
them  to  be  sent  to  hospital,  he  still  keeping  his  shop 
open,  and  spreading  the  disease  among  his  neighbours. 
After  the  death  of  one  of  his  children  he  borrowed  a 
suit  of  black  clothes  from  a  neighbour,  which  was  sent 
back  to  the  owner,  and  he  put  it  on  and  took  small- 
pox, and  died  within  a  fortnight." 

In  1880  Dr.  Wright,^  medical  officer  of  health  for 
Cheltenham,  writes  :  "  During  the  last  six  years  small- 
pox has  been  introduced  into  the  town  on  twelve 
separate  occasions  by  cases  which  .  .  .  were  imported 
from  infected  districts.     All  these  patients  I  removed 

1  Smallpox  and  Fever  Hospitals  Commission,  Minutes  of  Evidence,  Question 
1813.  2  Jitij,,^  Question  4241. 

3  Supplement  to  Tenth  Annual  Report  of  Local  Government  Board,  p.  100. 


52  PREVENTION  OF  EPIDEMICS 

into  the  Delancey  Hospital  as  soon  as  they  were  dis- 
covered, and  in  each  case  the  disease  never  extended 
beyond  the  house  in  which  it  first  occurred." 

Dr.  Seaton/  late  medical  officer  of  health  for  the 
Borough  of  Nottingham,  reports  in  1879  that  "thirty- 
seven  out  of  sixty  cases  removed  to  hospital  were  first 
attacks  in  households  that  contained  many  susceptible 
children  .  .  .  and  that  only  in  one  instance  did  a  second 
case  occur."  In  1879  scarlet  fever  broke  out  in  Settle, 
a  rural  sanitary  district  with  about  15,000  of  a  popula- 
tion. "Three  young  children  who  were  affected  with 
the  disease  were  at  once  admitted,  together  with  their 
mother  (into  the  Settle  Infectious  Hospital),  and  after 
disinfection,  both  of  premises  and  clothing,  two  elder 
children  who  were  the  main  bread-winners  of  the 
family  were  allowed  to  resume  their  work  at  a  neigh- 
bouring mill.  No  further  spread  took  place,  whereas 
in  several  adjoining  sanitary  districts,  having  no  means 
of  isolation,  scarlet  fever,  at  about  the  same  date, 
became  widely  prevalent." 

In  the  Solihull  rural  district,  with  a  population  of 
about  20,000,  Dr.  Page,  the  medical  officer  to  the 
hospital,  states  that  with  the  exception  of  one  or 
perhaps  two  cases  in  which  a  second  attack  of 
scarlet  fever  had  occurred  within  two  days  of  the 
removal  of  the  patient,  the  disease  having  obviously 
been  contracted  before  such  removal,  no  spread  of 
that  disease  had  taken  place  in  any  house  from  which 
the  first  patient  had  been  removed. 

^  Annual  Summary  for  1879,  by  Edward  Seaton,  M.  O.H. 


INFECTIOUS  DISEASE  NOTIFICATION  ACT  53 

It  will  thus  be  seen,  that,  by  means  of  hospital 
provision,  and  proper  disinfection,  the  danger  of 
infectious  disease  spreading  among  the  inmates  of 
even  small  houses  may  be  reduced  to  the  minimum, 
and  an  infected  house  and  family,  instead  of  being  a 
menace  to  the  neighbourhood  for  months,  may  be 
disinfected  and  rendered  harmless  in  a  few  days.  The 
various  infectious  diseases  can  be  recognised  sufficiently 
early  by  medical  men  ;  the  time  the  various  fevers  take 
incubating  in  the  system  after  infection  is  fairly  well 
known  ;  the  period  over  which  the  danger  of  infecting 
others  extends  can  be  reckoned  with  comparative 
precision  ;  powerful  agents  and  methods  for  destroy- 
ing infection  in  premises  and  clothing  have  been 
devised.  We  have  only  therefore  to  take  advantage 
of  the  knowledge  acquired,  to  be  able  to  check  the 
spread  of  infectious  diseases,  if  not  to  exterminate 
them  altogether. 

Until  the  Infectious  Disease  Notification  Act  was 
passed,  it  was  not  always  possible  to  find  out  such 
cases  in  time  to  have  much  effect  in  checking  the 
progress  of  an  epidemic.  Now  in  those  districts  where 
this  Act  has  been  adopted,  both  medical  practitioners 
and  householders  are  bound  forthwith  to  notify  all 
cases  of  infectious  disease  to  the  Local  Authority. 
This  Act  has  been  adopted  over  a  large  part  of  this 
country,  but  in  rural  districts  it  is  seldom  that  hospitals 
and  ambulances  are  provided.  Until  this  is  done,  the 
information  obtained  by  means  of  the  Infectious  Disease 
Notification  Act  in  checking  the  spread  of  epidemic 


54  PREVENTION  OF  EPIDEMICS 

diseases,  cannot  always  be  used  with  success.  Indeed 
it  is  impossible  in  some  cases  to  do  more  than  to  watch 
the  disease  gradually  spreading.  Even  without  hospitals 
the  information  collected  by  means  of  this  Act  is  of 
considerable  service  in  many  cases  in  preventing  the 
spread  of  infection. 


CHAPTER    IV 

The  Nature  of  Infection  and  its  Influence  on  the  Con- 
struction AND  Management  of  Isolation  Hospitals 

The  air  of  a  hospital  ward,  or  of  any  apartment,  where 
cases  of  infectious  disease  are  accommodated,  is  con- 
taminated by  gases,  which  issue  from  the  bodies  of  the 
inmates ;  more  particularly  from  the  lungs  by  the 
breath,  and  from  the  skin  by  perspiration,  and  by 
invisible  transpiration.  It  is  also  rendered  impure  by 
the  products  of  the  combustion  of  gas,  oil,  candles, 
etc.  These  gases  consist  of  carbonic  acid,  carbonic 
oxide,  ammonia,  sulphuretted  hydrogen,  etc.  They  are 
always  present  to  a  certain  extent,  but  with  ordinary 
ventilation  and  cleanliness,  they  are  prevented  from 
accumulating  to  the  degree  that  becomes  a  source  of 
danger. 

In  addition  to  these  gases,  however,  other  more 
dangerous  organic  products  are  given  off  from  the 
bodies  of  the  inmates,  in  the  breath,  perspiration,  and 
other  secretions  and  excretions.  These  are  the  pro- 
ducts of  the  tissue-waste  of  the  body,  which  is  more 
rapid  in  the  case  of  the  sick.  When  these  products 
accumulate  to  any  extent,  they  decompose,  make  the 


56  PREVENTION  OF  EPIDEMICS 

air  close,  and  cause  a  peculiar  foetid  smell,  which  is 
easily  noticed  on   entering  an   ill-ventilated    ward   or 
room.     Any  porous  material  used  in  the  construction 
of  a  ward  or  room,  such  as  a  soft  wooden  flooring,  or 
wooden    or   papered    or    plastered    walls,  is  liable   to 
absorb   them.       Here  they  undergo  further  changes, 
and  only  require  moisture  to  give  off  more  noxious 
effluvia.     These  products  consist  in  part  of  "  minute 
particles  of  solid  or  semi-solid  insoluble  matter,  derived 
directly  or  indirectly  from   the  bodies  of  patients  of 
which  they  once  formed  a  part :"  ^  such  as  epithelial,  or 
mucous,  or  pus  cells,  or  minute  particles  of  other  ex- 
cretions or  secretions.     Some  of  these  particles,  both 
before  and  after  removal  from  the  body,  afford  shelter 
and  nourishment  to  various  micro-organisms,  some  of 
which  are  harmless,  while  others  are  liable  to  cause, 
or  aggravate  disease.     Wherever  these  particles  find 
a  lodgment,  as  on  inequalities  of  walls  and  floors,  or 
are  absorbed  by  any  material  in  a  ward,  there  these 
micro-organisms    remain,   probably   in   a  dormant  or 
quiescent  condition,  but   retaining  their  vitality.      If, 
by  any   chance,   such    of   them   as   are  pathogenic  or 
disease-producing,   are    disturbed,    and    so    find   their 
way  into  the   body  of  any  of  the   Inmates,   they  are 
apt   to   multiply  in  his  system  and   cause  disease,  or 
otherwise  weaken  him  and  render  him  less  capable  of 
recovery    from    any    illness    from    which    he    may   be 
suffering. 

Before  the  nature  of  these  organisms  was  so  well 

1  Dr.  Billings,  Hospital  Construction  and  Management  (John  Hopkins),  p.  1 1. 


ILL- KEPT  HOSPITALS  57 

known  as  is  now  the  case,  Sir  John  Simon  ^  stated 
that  **  in  ill-kept  hospitals  wounds  go  on  badly ; 
instead  of  running  their  normal  courses  of  rapid  re- 
covery, they — whether  accidental  wounds,  or  wounds 
made  by  operative  surgery — undergo  certain  character- 
istic morbid  changes.  Erysipelas  will  frequently 
attack  them,  so  will  other  morbid  processes  akin  to 
erysipelas,  such  morbid  processes  as  those  of  gangrene, 
phagedaena,  or  putrefactions  of  effused  or  otherwise 
stagnant  blood,  and  reopenings  of  half-healed  arteries 
and  veins,  and  septic  and  suppurative  infections  of  the 
system,  and  so  forth.  .  .  .  And  if  the  hospital  receives 
lying-in  women,  these  infections  will  constitute  differ- 
ent forms  of  so-called  puerperal  fever."  "In  such 
exhalations  are  embodied  the  most  terrible  powers  of 
disease,  the  spreading  flames,  as  it  were,  of  some 
infections,  and  the  explosive  fuel  of  others,  and  any 
air  in  which  they  are  let  accumulate  soon  becomes  a 
very  atmosphere  of  death."  Since  that  time  specific 
micro-organisms  have  been  demonstrated  in,  and 
proved  to  be  the  cause  of,  the  various  diseases  or 
morbid  processes  enumerated  by  Sir  John  Simon. 

Long  before  micro-organisms  were  proved  to 
be  the  agents  of  infection,  Dr.  Burdon  Sanderson 
showed  that  "contagium"  consisted  of  particles,  and 
was  neither  fluid  nor  gaseous.  In  a  paper  published 
in  the  Twelfth  Report  of  the  Medical  Officer  of  the 
Privy  Council  in  1869,  on  "The  Intimate  Pathology  of 
Contagium,"   he  stated   that    contagium    was    neither 

^  Local  Government  Board  Report,  1863,  pp.  52  and  59. 


58  PREVENTION  OF  EPIDEMICS 

soluble  in  water,  nor  capable,  without  losing  its  proper- 
ties, of  assuming  the  form  of  vapour,  and  that  it  was 
not  possible  to  admit  that  contagium  was  an  insoluble 
solid  or  liquid,  without  admitting  at  the  same  time  that 
it  consists  of  separate  particles  which  scarcely  differ 
from  the  animal  liquids  in  which  they  are  suspended, 
either  in  their  specific  gravity,  or  in  the  degree  they 
affect  the  transmission  of  light.  He  diffused  vaccine 
lymph,  and  found  that  it  was  inert.  He  dissolved  a 
drop  of  lymph  in  a  large  volume  of  an  inert  liquid,  and 
found  its  action  proportionally  uncertain.  "  If,"  he 
states,  "  on  the  other  hand,  contagium  were  soluble  it 
could  not  be  explained,  for  in  that  case  each  of  the 
10,000  drops,  in  which  the  one  drop  had  been  dis- 
solved, would  be  equally  active.  Assuming  it  to  be 
particulate,  it  follows  that  the  myriads  of  particles, 
which  were  before  distribution  in  one  drop,  are 
scattered  through  10,000  drops;  and  inasmuch  as 
there  is  nothing  excepting  the  influence  of  currents,  to 
ensure  the  equal  distribution  of  the  particles,  it  is 
clear  that  in  some  regions  of  the  liquid,  the  distance 
from  each  other  will  be  greater,  in  others  less.  Con- 
sequently when  a  trace  of  the  liquid  thus  feebly  im- 
pregnated with  contagium  is  taken  up  on  the  point 
of  the  lancet,  the  chance  that  the  little  drop  will 
or  will  not  contain  particles  may  be  stated  numeric- 
ally, by  the  fraction  which  expresses  the  degree  of 
dilution." 

"  And  here  it  is  of  importance  to  notice  that  the 
same  explanation  applies  to  a  fact  of  common  observa- 


PATHOLOGY  OF  CONTAGIUM  59 

tion  with  respect  to  all  of  those  diseases  which  are 
contagious  at  a  distance.  The  question  is  frequently 
asked,  How  does  it  happen  that  a  person  may  be 
.  exposed  every  day  for  many  months  to  the  contagium 
of  typhus  with  immunity,  and  yet  be  eventually  attacked 
without  any  change  whatever  being  made,  either  in 
his  own  condition,  or  In  that  of  the  Infected  media  by 
which  he  is  surrounded  ?  If  contagium  were  gaseous, 
the  fact  would  be  inexplicable.  .  .  .  Assuming  it  to  be 
insoluble  and  particulate,  the  question  of  mediate  con- 
tagion must,  like  that  of  direct  contagion,  be  one  of 
chance.  Just  as  In  the  case  of  Inoculation,  the  effect 
of  dilution  shows  itself  exclusively  In  the  proportion  of 
failures  to  the  total  number  of  Insertions,  so  In  ex- 
posure to  Infected  air,  the  effect  of  distribution  of  the 
poison  through  a  large  volume  of  air  shows  Itself  in 
the  proportion  of  escapes  to  the  total  number  of 
exposures  which  the  individual  passes  through.  And 
just  as  In  the  former  instance,  the  last  Inoculation  of  a 
series  is  just  as  likely  to  be  the  one  by  which  a  particle 
of  contagium  is  introduced  as  the  first,  so  in  mediate 
contagion  the  last  exposure  is  just  as  likely  to  be  the 
effectual  one  as  the  first." 

"  With  reference  to  their  mode  of  action,  we  have 
examined  into  those  considerations  which  seem  to 
render  It  probable  that  they  are  organised  beings,  and 
that  their  power  of  producing  disease  is  due  to  their, 
organic  development ;  and  we  have  accepted  the 
doctrine  as  the  only  one  which  affords  a  satisfactory 
explanation  of  the  facts  of  infection,  and  in  particular, 


6o  PREVENTION  OF  EPIDEMICS 

of  those  which  tend  to  show  that  within  the  body  of 
the  infected  individual  the  particles  of  contagium 
rapidly  reproduce  themselves,  while  out  of  the  body 
they  are  capable  of  resisting  for  very  long  periods  the . 
influence  of  conditions,  which  if  not  restrained  by 
organic  action  would  produce  chemical  decomposi- 
tion." 

Within  the  last  fifteen  years,  great  improvement 
has  been  made  in  the  methods  by  which  the  nature  of 
these  micro-organisms  can  be  investigated.  Formerly 
various  species  of  these  organisms  were,  on  account  of 
the  defects  of  the  methods  in  use,  liable  to  get  mixed 
in  the  process  of  examination  and  cause  confusion. 
There  was  no  efficient  way  of  separating  one  species 
from  another,  and  of  cultivating  it  separately  so  as  to 
arrive  at  any  reliable  conclusion  as  to  its  behaviour 
under  various  conditions. 

Pasteur  opened  the  way  for  future  Vv^orkers  by  his 
method  of  obtaining  a  comparatively  pure  culture  of 
the  micro-organism  of  yeast  by  means  of  food  more 
suited  to  its  nutrition  than  to  that  of  other  micro- 
organisms usually  associated  with  it.  This  method 
was  improved  by  Klebs  in  1873,  by  combining  the 
fractional  method  with  that  of  providing  specially 
prepared  food.  Sir  William  Roberts  and  Cohn  a  few 
years  later  found  that  some  species  were  more  easily 
killed  by  heat,  and  in  this  way  obtained  pure  specimens, 
of  some  species  of  micro-organisms.  In  1878-79,  Sir 
Joseph  Lister  and  Dr.  Naegeli  obtained  pure  cultures 
by  distributing  a  number  of  organisms  in  large  quan- 


PROGRESS   OF  BACTERIOLOGY  6i 

titles  of  fluid,  and  making  greater  and  greater  dilution 
of  these  organisms  in  broth  until  the  dilution  was  such 
that  a  single  drop  did  not  contain  more  than  a  single 
organism.^  In  1877  Sir  William  Roberts,  in  an  address 
delivered  to  the  British  Medical  Association,  "  On 
Spontaneous  Generation  and  the  Doctrine  of  the  Con- 
tagium  Vivum,"  showed  that  organic  matter  has  no 
inherent  power  of  generating  bacteria,  and  that  bacteria 
are  the  actual  agents  of  decomposition.  "As  to  the 
nature  of  the  infecting  agents,"  he  states,  "we  can  say- 
positively  that  they  must  consist  of  solid  particles, 
otherwise  they  could  not  be  separated  by  filtration 
through  cotton  wool."  "  Professor  Tyndall  has  demon- 
strated that  air  which  is  optically  pure — that  is,  air 
which  is  free  from  particles,  has  no  fecundating  power. 
Dr.  Burdon  Sanderson,  writing  in  1874,  inferred  from 
the  persistence  of  the  contagium  of  splenic  fever  out- 
side the  body,  in  stables  and  other  places,  and  its  short- 
lived and  fugitive  existence  in  the  blood,  that  the 
micro-organism  must  have  two  states  of  existence, 
namely,  that  of  the  perishable  bacteria  found  in  the 
blood,  and  some  other  more  permanent  form  in  which 
like  seeds  or  spores  they  were  capable  of  surviving  for 
an  indefinite  period.  Professor  Cohn,  guided  by  the 
botanical  character  of  the  rods,  came  to  the  same 
conclusions.  These  previsions.  Sir  William  Roberts 
states,  were  proved  by  the  researches  of  Koch  to  be 


1  Bacteria  and  their  Products,  by  Dr.  German  Sims  Woodhead,  p.  304. 

2  Spontaneous  Generation  attd  the  Doctrine  of  the   Contagiztm  Vivum,  by  Sir 
William  Roberts,  M.D.,  p.  12. 


62  PREVENTION  OF  EPIDEMICS 

perfectly  exact.^  Koch  cultivated  the  bacillus  of 
splenic  fever  {bacillus  anthracis)  in  a  drop  of  the  aque- 
ous humour  of  the  eye,  in  an  incubator  at  a  tempera- 
ture of  about  98.4°  Fahr.,  between  two  microscopic 
slides,  and  examined  the  progress  of  events  now  and 
then  under  the  microscope,  and  he  actually  saw  the 
spores  or  seeds  forming.  He  found  that  mice  were 
peculiarly  liable  to  splenic  fever,  and  by  experimenting 
on  them  he  found  that  the  bacillus  anthracis  lived  only 
for  a  comparatively  short  time,  but  that  the  spores  or 
seeds  retained  their  vitality  for  an  indefinite  period. 
"They  could  be  reduced  to  dust,  wetted  and  dried 
repeatedly,  kept  in  putrefying  liquids  for  weeks,  and 
yet  at  the  end  of  four  years  they  still  displayed  an 
undiminished  virulence."^ 

In  1 88 1  Koch^  published  his  improved  methods, 
for  the  investigation  of  the  nature  of  pathogenic 
organisms.  This  consisted  mainly  of  a  process  of 
rendering  the  bacteria  in  fluids  and  animal  tissues  visible 
by  means  of  staining  reagents,  and  of  obtaining  pure 
cultivations  of  different  species  of  micro-organisms  by 
means  of  solid  or  semi-solid  media,  instead  of  the  fluid 
in  which  bacteria  were  previously  cultivated.  He 
states  : — "  It  being  perfectly  clear  that  efforts  in  this 
direction  are  in  vain,  I  have  abandoned  the  principles 
on  which  pure  cultures  have  hitherto  been  conducted, 

1  Koch,  "Aetologie  d.  Milz-Brand-Krankheit "  in  Cohn's  Beitrage  z.  Biologie 
d.  PJlanzen,  Bd.  II.  Heft  ii.  1876. 

2  On  the  Doctrine  of  the  Cojitagiiiin  Viviun,  by  Sir  William  Roberts,  M.D., 

P-  37- 

3  hlitlheilimgen  aiis  dein  kaiserlichen   Gesundheitsa7)ite,  vol.  i.,  Berlin,    1 88 1. 
Translated  by  Victor  Horsley,  B.S.,  F.  R.C.S.,  for  New  Sydenham  Society. 


KOCH'S  METHOD   OF  STAINING  63 

and  have  struck  out  a  new  path,  to  which  I  was  led  by 
a  simple  observation  which  any  one  can  repeat.  If  a 
boiled  potato  is  divided,  and  the  cut  surfaces  exposed 
to  the  air  for  a  few  hours,  and  then  placed  in  a  moist 
chamber  (as,  for  instance,  on  a  plate  under  a  bell  jar 
lined  with  wet  filter  paper)  so  as  to  prevent  drying, 
there  will  be  found  by  the  second  or  third  day  (accord- 
ing to  the  temperature  of  the  room)  on  the  surface  of 
the  potato  numerous  and  very  varied  droplets,  almost 
all  of  which  appear  to  differ  from  each  other.  A  few 
of  these  droplets  are  white  and  porcellaneous,  while 
others  are  yellow,  brown,  gray,  and  reddish  ;  and 
while  some  appear  like  a  flattened-out  drop  of  water, 
others  are  hemispherical  or  warty.  All  grow  more  or 
less  rapidly,  and  between  them  appears  the  mycelium 
of  the  higher  fungi ;  later  the  solitary  droplets  become 
fused  together,  and  soon  marked  decomposition  of  the 
potato  occurs.  If  a  specimen  is  taken  from  each  of 
the  droplets,  so  long  as  they  remain  distinctly  isolated 
from  each  other,  and  is  examined  by  drying  and  stain- 
ing, a  layer  of  it  on  a  cover  glass,  it  will  be  seen  that 
each  is  composed  of  a  perfectly  definite  kind  of  micro- 
orofanism."  ^ 

With  few  exceptions,  every  droplet  or  colony  is  a 
pure  culture,  and  remains  so  until  by  growth  it  pushes 
into  the  territory  of  a  neighbour ;  the  exceptions 
being  those  cases  where  two  spores  fell  quite  close 
to  one  another.      If,   on    the    other  hand,   the    spores 

1  Mittheiliingen  aiis  dan  kaiserlichen  Gesiindheitsamte,  vol.  i.,  p.  37:    Berlin 
1 88 1.     Translated  by  Victor  Horsley,  B.S.,  F.R.C.S.,  for  New  Sydenham  Society. 


64  PREVENTION  OF  EPIDEMICS 

were  to  fall  into  a  nutrient  fluid,  the  organisms  endowed 
with  motion  would  have  dispersed  themselves  rapidly 
throughout  the  liquid,  and  mixed  with  those  not  so 
endowed.  Some  bacteria,  however,  were  found  not  to 
grow  when  planted  on  the  surface  of  the  potato. 
This  difficulty,  however,  was  surmounted  by  pre- 
paring nutrient  gelatine,  to  be  used  in  a  similar 
manner. 

By  the  introduction  of  the  exact  method  of  cultiva- 
tion of  bacteria  on  solid  media  and  of  staining  bacteria, 
"there  has  suddenly  set  in  a  flow  of  researches  and 
discoveries,  which,  like  a  snowball  in  rolling  from  the 
top  of  a  snowhill,  is  constantly  increasing  in  size,  and 
its  advent  is  felt  in  wider  and  wider  circles."  ^  Since 
that  time  the  bacilhis  tuberculosis  has  been  conclu- 
sively proved  to  be  the  cause  of  consumption.  In 
1883  Koch  demonstrated  that  this  organism  could  be 
separated  from  the  tissues  of  the  body,  cultivated 
outside  the  body  in  nutrient  media,  and  was  capable 
of  causing  consumption  when  introduced  into  the  body 
of  some  animals,  and  further,  that  the  same  organisms 
were  found  in  the  diseased  tissues  of  these  animals.^ 
It  was  also  found  that  "tubercle  bacilli  taken  from  the 
lungs  of  phthisical  bodies,  and  buried  for  years,  still 
possess  their  characteristic  reaction,  and  are  capable 
of  producing  tuberculosis  on  inoculation.  This  would 
mean  that  the  tubercle  bacillus,  even  after  years,  was 


1  Klein  on  "  Pathology  of  Infectious  Diseases,"  Hygie7te,  and  Ptiblic  Healthy 
(Stevenson  and  Murphy),  vol  ii.  p.  34. 

2  Bacteria  and  their  Products,  G.  S.  Woodhead,  p.  206. 


ANTHRAX— DIPHTHERIA  65 

Still  living  and  capable  of  carrying  on  an  existence 
outside  the  living  human  or  animal  body."^ 

The  anthrax  bacillus,  which  is  the  cause  of  wool- 
sorters'  disease  in  human  beings,  has  been  described 
so  long  ago  as  1849  and  1850  by  Pollender,  Rayer, 
and  Davaine,  as  occurring  in  the  blood  of  animals 
dying  from  splenic  fever.  It  was  left  to  Koch,  how- 
ever, to  give  absolute  proof  that  this  organism  was  the 
actual  cause  of  splenic  fever.  To  this  I  have  already 
referred.  In  his  Reports  to  the  Medical  Officer  of 
the  Local  Government  Board  in  1881  and  1882,  Mr, 
Spears  conclusively  proved  that  woolsorters'  and  rag- 
sorters'  disease  was  caused  by  infection  from  the  dust 
of  infected  wool  and  hides.  The  blood  in  the  general 
circulation,  and  in  all  the  vessels  of  the  organs  of  persons 
dying  from  these  diseases,  contains  the  bacilli  anthracis. 

The  bacillus  of  diphtheria,  isolated  by  Loffler, 
called  by  Klein  the  Klebs-Loffler  bacillus,  has  been 
conclusively  proved  to  be  the  cause  of  diphtheria.  Dr. 
Woodhead  states  that  diphtheria  is  entirely  dependent 
for  its  specific  symptoms  on  the  diphtheria  bacillus, 
experiment  corroborating  clinical  observation  in  a 
most  remarkable  manner.^  This  bacillus  also  lives 
outside  the  human  body.  It  lives  in  gelatine,  and 
grows  luxuriantly  in  milk.  By  subcutaneous  inoculation 
it  causes  diphtheria  in  guinea  pigs.^     Cats  have  been 

^  "  Pathology  of  Infectious  Diseases,"  Treatise  071  Hygiene  ajid Public  Health, 
vol.  ii.  p.  75  (Stevenson  and  Murphy). 

2  Address  on  Bacteriology,  delivered  before  the  British  Medical  Association 
at  Nottingham,  1892. 

2  "  Pathology  of  Infectious  Diseases,"  Treatise  on  Hygiene  and  Public  Health, 
vol.  ii.'p.  156  (Stevenson  and  Murphy). 

F 


66  PREVENTION  OF  EPIDEMICS 


known  to  contract  the  disease.  "In  houses  where 
human  diphtheria  obtained,  cats  have  been  known  to 
become  ill  either  antecedently,  or  coincidently,  or  subse- 
quently :  they  appear  to  have  some  kind  of  throat 
illness  and  cannot  swallow ;  they  sneeze  and  their  eyes 
water ;  as  a  rule  bronchial  mischief  is  noticed  early, 
and  if  the  disease  is  protracted  through  several  weeks, 
as  it  sometimes  is,  they  become  much  emaciated  and 
die."^  Klein  also  states  that  such  a  disease  exists 
naturally  among  cats,  and  in  one  case  he  had  seen 
such  a  cat  after  several  weeks'  illness,  showing  para- 
lysis of  the  hind  extremities,  probably  the  same  as 
diphtheritic  paralysis  in  a  human  being.  He  had  the 
opportunity  of  examining  sections  through  diseased 
portions  of  the  lungs  of  two  cats  dead  of  such  a  disease, 
and  he  found  diphtheria  bacilli  in  considerable  numbers. 
He  also  gives  very  important  evidence  in  favour  of  the 
belief  that  cows  suffer  from  diphtheria,  and  communi- 
cate the  disease  in  the  milk  to  human  beings. 

The  strepto-coccus  scarlatinas  has  been  found  to  be 
associated  with  scarlet  fever  in  human  beings.  Klein 
has  been  able  to  produce  a  definite  eruptive  disease  in 
six  milch  cows,  on  the  skin  generally,  and  on  the  teats 
and  udders  particularly,  by  inoculating  them  with  the 
human  strepto-coccus  scarlatinse.  Cows  suffering  from 
a  similar  disease  have  by  their  milk  communicated 
scarlet  fever  to  human  beings. 

Typhoid  bacillus.  —  Gaffky^  is  the    first    to    have 

1  Dr.  Klein  in  Report  of  Medical  Officer,  Local  Government  Board,  1889. 
2  MillheiL  azis  defn  kais.  Gesundheiisainte,  vol.  ii.  p.  372. 


SCARLET  FEVER— TYPHOID  FEVER  67 

successfully  isolated  and  cultivated  this  bacillus,  shown 
by  Eberth  to  be  found  in  the  swollen  mesenteric 
glands  of  persons  who  have  died  of  typhoid  fever. 
This  bacillus  grows  on  gelatine,  in  alkaline  broth,  in 
blood  serum,  and  on  boiled  potatoes  and  other  media. 
Klein  is  not  satisfied  that  this  is  the  bacillus  of  typhoid 
fever.  He,  however,  states  that-^  "the  virus  must  be  a 
microbe  which  evidently  can  live  and  thrive  in  sewage 
and  on  the  soil ;  further,  that  it  can  maintain  its  vitality 
even  when  placed  in  such  a  poor  medium  as  water ;  it 
must  be  possessed  of  considerable  resistance  towards 
putrefaction,  towards  cold,  and  towards  the  gastric  juice; 
when  brought  in  the  stools  of  a  typhoid  fever  case  into 
drains,  cesspools,  and  the  like,  it  must  be  capable  of 
preserving  its  life  for  an  indefinite  time.  All  these 
are  requirements  postulated  by  what  is  known  of 
the  epidemiological  relations  of  typhoid  fever." 

Micro-organisms  have  also  been  demonstrated  to 
be  the  cause  of  cholera,  epidemic  pneumonia,  relapsing 
fever,  erysipelas,  septicaemia,  tetanus,  and  some  diseases 
of  animals.  On  the  other  hand,  in  typhus  fever, 
whooping  cough,  measles,  varicella,  and  oriental 
plague,  the  existence  of  pathogenic  organisms  is  as  yet 
a  matter  of  pure  inference.  Klein,  however,  states  in 
the  exhaustive  contribution  to  the  pathology  of  infec- 
tious diseases  already  referred  to,  that  "the  evidence 
that  infectious  diseases  owe  their  origin  to  specific, 
well    characterised    micro-organisms    is    no   longer   a 

^   "  Pathology  of  Infectious  Diseases,"  Treatise  on  Hygiene  and  Public  Health, 
vol.  ii.  p.  167  (Stevenson  and  Murphy). 


68  PREVENTION  OF  EPIDEMICS 

matter  of  pure  assumption,  but  one  of  exact  science. 
.  .  ,  Just  as  a  chemist  is  enabled  to  detect  and  to 
demonstrate  with  tolerable  exactness  the  existence  in 
special  cases  of  a  chemical  poison, — e.g.  arsenic,  phos- 
phorus, strychnine,  etc. — the  material  that  has  caused 
disease  and  death,  so  nowadays  can  the  pathologist  by 
microscopical,  cultural,  and  animal  experiments  demon- 
strate the  specific  inateries  niorbi.'' 

"The  study  of  micro-organisms  connected  with 
specific  disease,  i.e.  their  contagia,  their  nature,  habits, 
and  power  of  growth  outside  and  within  an  infected 
individual,  the  manner  in  which  they  leave,  and  in 
which  they  enter,  the  human  and  animal  organism,  the 
nature  of  the  changes  which  they  induce  in  the  material 
in  which  they  grow  and  multiply,  be  that  material  the 
human  or  animal  organism,  or  organic  matter  outside 
these — all  this  is  now  well  understood." 

The  micro-organisms  of  many  diseases  have  thus 
been  proved  by  bacteriologists  to  live  and  multiply  in 
various  media  outside  the  human  body  for  varying 
periods,  and  to  produce  the  same  disease  if,  by  inocula- 
tion or  otherwise,  they  gain  access  into  the  body  of  an 
animal  or  a  human  being.  They  have  also  proved 
that  some  micro-organisms  have  the  power  of  forming 
spores  or  seeds  infinitely  more  hardy  than  themselves 
(just  as  the  ripe  seeds  are  more  hardy  than  the  parent 
plant),  and  that  these  spores,  after  apparently  any 
amount  of  ill  usage,  retain  their  vitality  for  years,  and 
are  after  all  capable  of  germinating,  and  thereby  re- 
producing disease. 


BACTERIOLOGY  AND  EPIDEMIOLOGY  69 

It  may  now  be  shown  how  the  experience  of 
bacteriologists  in  this  respect  coincides  with  that  of 
other  observers  in  the  field  of  preventive  medicine. 

Surgeon-General  Billings/  U.S.A.,  states  that  he 
*'had  seen  scarlatina  produced  by  some  of  these 
particles  which  had  been  preserved  in  a  blanket  care- 
fully packed  away  for  years." 

The  following  case  is  quoted  from  the  Boston 
Post :^ — "A  large  picture  book  had  been  used  by  a 
boy  during  his  illness  with  scarlet  fever  in  1846.  The 
book  was  packed  away  in  a  trunk  for  twenty-six  years. 
Finally  it  was  brought  to  England  and  a  child  two 
years  old  became  its  possessor.  A  fortnight  after 
receiving  it  he  was  attacked  with  scarlet  fever,  and  to 
the  doctors  attending  the  case  there  appeared  no  other 
means  by  which  the  child  could  have  been  infected." 

Dr.  Carpenter,  in  a  paper  read  before  the  British 
Medical  Association  in  1875,  records  a  case^  in  which 
"a  proprietor  ordered  the  removal  of  some  old  houses 
which  had  lain  in  a  state  of  ruin  and  uninhabitable 
for  many  years.  Eight  men  were  employed  in  digging 
the  walls,  and  every  one  was  attacked  with  smallpox, 
the  germs  of  that  disease  having  lain  in  these  houses 
all  those  years." 

Dr.  Thorne  Thorne^  states  that  instances  have 
come  under  his  own  notice  in  which  the  facts  warranted 


^  Hospital  Construction  mtd  Management,  p.  12  (John  Hopkins). 

2  Epidemics,  etc.,  p.  264,  by  the  Hon.  Rollo  Russell. 

3  This  case  is  believed  to  have  occurred  in  the  Island  of  Mull  :  Dr.  Carpenter 
jot  the  information  second-hand  from  a  practitioner  in  Oban. 

*   Transactions  of  the  Epidemiological  Society,  vol.  iv.  pt.  2,  p.  234. 


JO  PREVENTION  OF  EPIDEMICS 

the  conclusion  that  the  poison  of  diphtheria  had  been 
retained  for  months  about  premises  in  which  cases  of 
this  disease  had  previously  occurred. 

He  also  states  in  regard  to  enteric  fever:  "I 
know  a  detached  house  which  stands  in  large  grounds 
in  a  country  district,  and  which  was  occupied  by  a 
groom  and  his  family,  amongst  whom  enteric  fever 
prevailed  in  the  autumn  of  1872,  one  case  being 
fatal.  This  family  continued  to  occupy  the  house  for 
nearly  two  years  after  this  occurrence,  but  they  left  it 
some  time  in  1874,  in  consequence  of  the  departure  of 
the  owner  of  the  estate  on  which  it  stood.  From  that 
time  the  house  remained  unoccupied  until  February 
1876,  when  it  was  retenanted  by  new  inmates,  and 
exactly  within  fourteen  days  of  these  latter  taking  up 
their  abode  there,  enteric  fever  broke  out  amongst  them, 
and  a  most  careful  inquiry  led  both  the  medical  man 
in  attendance  and  myself  to  the  conclusion  that  the 
disease  was  not  imported.  I  also  know  an  isolated 
parsonage  in  which  the  families  of  two  successive  vicars 
have  been  attacked  with  enteric  fever."  He  also 
states  that  Dr.  Ogle,  in  some  of  his  reports  on  the 
sanitary  condition  of  East  Herts  district,  refers  to 
cases  in  which  attacks  of  this  disease  have  in  successive 
autumns  occurred  in  isolated  dwellings  where,  so  far  as 
could  be  ascertained  by  the  strictest  investigation,  no 
new  source  of  infection  could  have  come  into  operation. 

Dr.  Klein  states  that  "  it  is  also  known  that  a  room 
in  which  a  diphtheria  case  has  once  existed,  may  for 
years  harbour  the  contagium  of  diphtheria,  so  that  any 


BACTERIOLOGY  AND  EPIDEMIOLOGY  71 

new  comer  or  inhabitant  may  contract  the  disease  ; 
moreover,  it  is  l^nown  that  in  a  locahty  in  which 
diphtheria  has  once  been  rife,  the  disease  may  at  any 
time  re-appear,  and  in  these  instances  the  transmission 
of  the  contagium  from  sewers  is  maintained  by  some 
sanitarians." 

I  have  already  referred  to  an  isolated  farmhouse  in 
which  outbreaks  of  typhoid  fever  occurred  in  1889, 
1890,  and  1892.  From  a  careful  consideration  of  the 
facts  of  this  case,  I  am  convinced  that  the  infection 
remained  about  the  house  during  that  time.  There 
was  another  case  of  an  isolated  crofter's  house  separated 
by  about  one  mile  of  uneven  hilly  land  from  any  other 
dwelling.  In  1881  five  of  the  inmates  of  this  house 
suffered  from  typhoid  fever,  one  of  whom  died  in  1882. 
In  1883  another  inmate  died  of  the  same  disease.  In 
1884  another  death  occurred  in  the  house,  the  cause  of 
death  being  registered  as  "perforation  of  the  bowels," 
which  is  a  frequent  occurrence  in  typhoid  fever.  In 
1887  another  of  the  inmates  died  from  diarrhoea,  which 
is  also  a  symptom  of  typhoid.  In  the  autumn  of  1889 
two  boys  from  a  town  distant  about  fourteen  miles 
lived  in  this  house  for  a  month.  They  returned  home 
ill  with  this  fever.  At  the  time  of  the  first  outbreak 
in  1 88 1  several  families  in  a  neighbouring  township 
are  stated  to  have  suffered  from  typhoid  fever,  and  the 
infection  is  believed  to  have  been  conveyed  into  the 
house  from  them.  Since  that  time  there  is  no  history 
of  the  disease  in  the  neighbourhood  of  this  house,  and 
a  careful  inquiry  failed  to  discover  any  way  by  which 


72  PREVENTION  OF  EPIDEMICS 

it  was  again  introduced  into  the  family.  There  was 
no  W.C.  attached  to  this  house.  It  was  without  any 
sewers  or  drains.  The  water  supply  was  pure.  The 
walls  were  damp  and  mildewed.  The  floor  in  one 
apartment  consisted  of  mud,  in  another,  of  damp, 
rotting  boards.  The  ground  against  the  back  wall 
was  considerably  above  the  level  of  the  floor.  The 
walls  were  built  of  rough  unhewn  stones,  and  the  rain 
water  trickled  down  the  outside  from  the  thatched  roof. 
The  soil  about  the  house  was  more  or  less  saturated 
with  organic  matter,  animal  and  vegetable.  I  know 
of  two  other  houses  where  typhoid  fever  broke  out 
more  than  once,  under  almost  similar  circumstances. 

Dr.  Maxwell  Ross,  county  medical  officer  for 
Dumfriesshire,  in  his  first  Annual  Report,  states : 
"There  were  two  cases  [of  typhoid  fever]  in 
St.  Mungo,  one  of  them  in  a  house  in  which  the 
germs  of  fever  seemed  to  have  lurked  for  years,  it 
having  become  one  of  the  plague  spots  of  the 
county." 

It  will  thus  be  seen  that  the  facts  proved  by 
bacteriologists  regarding  the  ability  of  the  organisms 
of  infectious  disease  to  live  outside  the  human  body 
and  to  retain  their  pathogenic  power,  exactly  agree 
with  the  experience  of  observers  who  noted  the 
behaviour  of  epidemic  disease. 

There  appears  to  be  some  evidence  in  favour  of 
the  conclusion,  that  the  organism  or  agent  of  infection, 
in  the  case  of  some  diseases,  is  less  capable  of 
retaining    its    vitality    or   power   of   infection    outside 


SOURCES   OF  DANGER  IN  ISOLATION  HOSPITALS    72, 

the  human  body,  than  in  the  case  of  some  other 
diseases.  I  know  myself,  for  example,  of  an  island 
on  the  west  coast  of  Scotland  where  whooping- 
cough  was  introduced  about  twenty  years  ago.  A 
large  number  of  the  population  suffered  from  the 
disease.  There  was  no  system  of  disinfection  followed. 
Many  of  the  houses  afforded  innumerable  lurking-' 
places  for  the  organisms  of  infection,  yet  children 
were  born  and  families  reared  in  these  houses  and  no 
one  suffered  from  whooping  -  cough  until  last  year, 
when  the  disease  was  again  introduced  by  visitors 
and  spread  rapidly.  I  have  also  never  been  able 
to  trace  an  outbreak  of  measles  to  infection  remaining 
in  or  about  dwellings.  I  have  seen  it  spread  until, 
as  it  were,  the  fuel  was  exhausted,  and  then  dis- 
appear for  many  years,  until  the  infection  was  again 
introduced. 

There  seems  therefore  to  be  some  grounds  for  the 
belief  that  the  organisms  of  these  diseases  may  not 
be  able  to  live  in  the  same  media  as  those  of  other 
diseases,  and  the  fact  that  bacteriologists  have  not  yet 
been  able  to  isolate  them  favours  this  view. 

Such  are  the  special  impurities  or  sources  of 
danger  to  be  guarded  against  in  the  isolation  of 
infectious  disease,  and  more  particularly  in  the  con- 
struction and  management  of  Isolation  Hospitals. 
Organisms  lurk  in  inequalities  of  floors  and  crevices 
of  walls.  They  are  also  liable  to  be  absorbed  by  the 
bedclothes,  bedding,  and  other  articles  of  furniture. 
If  the  ventilation  is  defective,  or  cleanliness  neglected. 


74  PREVENTION  OF  EPIDEMICS 

the  air  gets  contaminated  and  disease  spreads  from 
the  patients  to  the  attendants,  or  from  one  patient  to 
another.  If  a  hospital  is  properly  constructed  and 
designed,  and  "Jf  proper  ward  discipline  exists,  no 
patient  is  allowed  to  expose  himself  to  the  risk  of 
close  intercourse  with  cases  of  contagious  diseases, 
and,  subject  to  that  condition,  most  morbid  poisons  are 
of  little  effect."  ..."  Contagion  which  will  not 
spread  except  by  inoculation,  or  by  the  kindred  agency 
of  dirty  bedding  or  dirty  towels,  or  dirty  sponges,  or 
dirty  fingers,  or  by  the  drinking  of  polluted  water, 
or  by  the  effluvia  from  drains  or  cesspools,  ought 
to  be  absolutely  incommunicable  in  hospitals.  So 
ought  those  to  be  where  pus,  or  matters  like  pus,  are 
abundantly  floating  in  the  air."^  Drs.  Thomson  and 
Rainy  made  an  examination  of  the  air  in  hospital 
wards  in  1854,  and  found  floating  in  the  air  of  one 
of  the  wards  of  St.  Thomas's  Hospital,  minute  hairs, 
particles  of  smoke,  epidermic  scales,  vegetable  fibres, 
starch  granules,  as  well  as  living  forms,  vegetable  and 
animal,  such  as  vibriones  and  the  mycelia  of  fungi. 
In  1 86 1,  M.  Chalvet  of  St.  Louis  Hospital,  found  a 
large  quantity  of  floating  inorganic  matter  in  the 
wards  of  that  hospital.  M.  Kullman  made  an  analysis 
of  the  wall  plaster  of  the  walls  and  found  that  46  per 
cent  was  organic  matter.  Experiments  were  made 
by  M.  Broca,^  which  showed  the  presence  of  micro- 
cocci and  other  bacteria,  of  pus  globules,  and  of  spores 

1  Report  to  Local  Government  Board,  Sir  John  Simon,  1863,  p.  56. 
2  Revue  Med.  de  Vest,  Revue  de  Therap.,  Paris,  1874. 


ANTISEPTICS  IN  SURGICAL  HOSPITALS  75 

of  epiphytes  and  other  organisms  in  the  air,  and  on 
and  within  the  material  of  the  walls  of  wards  that 
have  been  long  used.^ 

Carnelley  ^  found  in  clean  one-roomed  houses  180 
bacteria  per  10  litres  [of  air] ;  in  dirty  houses,  410 ;  in 
very  dirty,  930;  in  naturally  ventilated  schools,  1250; 
in  mechanically  ventilated  schools,  300. 

A  patient  who  has  undergone  an  operation,  or  who 
has  much  broken  skin,  is  specially  liable  to  be  infected 
by  micro  -  organisms  from  any  of  the  surrounding 
media.  So  much  is  this  the  case  that  the  progress 
of  surgical  cases  in  a  ward  may  be  looked  upon  as 
a  sensitive  test  of  its  healthiness.  This  is  owing 
to  the  fact  that  in  addition  to  the  danger,  present 
in  all  hospitals,  of  the  agents  of  disease  gaining  access 
into  the  body  of  a  patient  by  the  respiratory  system 
and  alimentary  canal,  there  is  here  another  mode  of 
access  for  micro-organisms  due  to  lesions  of  the  skin 
resulting  from  operations  and  various  diseases.  The 
danger  has  of  recent  years  been  much  lessened  by  the 
antiseptic  method  of  treatment  initiated  and  success- 
fully practised  by  Sir  Joseph  Lister. 

With  reference  to  the  value  of  this  method  of 
treating  wounds  in  unhealthy  hospitals,  Dr.  Burdon 
Sanderson  writes  as  follows  of  Halle :  "It  is  Im- 
possible to  conceive  a  more  favourable  locality  for 
making  an  experiment  of  such  a  nature  ;  first,  because 
of  the  extraordinary  rapid  progress  of  the  manufactures 

1  Sir  Douglas  Galton. 

2  "The  Carbonic  Acid,  Organic  Matter,  and  Micro-organisms  in  Air,  more 
especially  of  Dwellings  and  Schools,"  T7'ans.  of  Roy.  Soc.  of  London,  1887. 


76  PREVENTION  OF  EPIDEMICS 

of  the  town,  which  has  rendered  the  hospital  too  small 
for  its  requirements,  and  consequently  the  proportion  of 
severe  cases  (as  I  was  able  to  observe  on  going  round 
the  wards)  was  very  large  ;  and,  secondly,  because  the 
hospital  itself  is,  not  perhaps  the  worst,  but  one  of  the 
worst  that  I  have  ever  seen.  Situated  in  the  very  centre 
of  the  town,  overshadowed  by  a  huge  ecclesiastical 
building,  and  having  for  wards  low  rooms,  each  of 
which  communicates  with  a  latrine  and  has  its  beds  so 
close  that  there  is  scarcely  room  to  pass  between  them, 
the  hospital  presents  every  circumstance  likely  to  lead 
to  the  development  of  the  worst  traumatic  affections. 
It  is  in  such  wards  as  these  that  compound  fractures 
and  resections  have  been  treated  with  a  success  which 
is  up  to  the  best  results  of  London  surgery.  In  a 
word,  the  influence  of  the  most  unfavourable  conditions 
which  can  be  conceived  (the  disastrous  effects  of 
which  were  before  so  overpowering  that  to  Prof 
Volkmann  his  clinical  work  had  become  a  burden 
instead  of  a  joy),  have  been  simply  neutralised  by  the 
conscientious  carrying  out  in  all  its  details,  with  the 
earnest  co-operation  of  the  whole  staff  of  the  hospital, 
of  the  Edinburgh  method."^ 

The  antiseptic  method  can  thus  be  shown  to  be 
singularly  successful  in  preventing  the  micro-organisms 
of  various  diseases  from  gaining  access  into  the  human 
system  through  wounds  and  other  lesions  of  the  skin. 
There   is   no   similar  specific   method   to  prevent  the 

1   The  Infective  Processes  of  Disease.      Lecture  delivered  in  the  theatre  of  the 
University  of  London,  by  Dr.  Burdon  Saunderson. 


ANTISEPTICS  IN  ISOLATION  HOSPITALS  yj 

micro-organisms  of  the  ordinary  infectious  diseases 
from  entering  the  system,  in  the  breath  or  in  food  or 
water.  It  is  therefore  all  the  more  necessary  that  in 
Isolation  Hospitals  the  wards  should  be  so  constructed 
as  to  allow  almost  an  unlimited  supply  of  fresh  air,  and 
ample  room  for  each  patient,  and  that  the  material  used 
in  their  construction  and  furnishing  be  such  as  not 
to  retain  or  absorb  the  organisms  of  infection.  This 
is  particularly  necessary  in  small  hospitals,  the  wards  of 
which  may  be  used  at  one  time  for  one  infectious 
disease,  and  at  other  times  for  other  infectious 
diseases. 


CHAPTER   V 

The  Establishment  and  Erection  of  Isolation  Hospitals — 

Preliminary 

The  expense  of  erecting  and  maintaining-  Isolation 
Hospitals  may  at  first  sight  appear  to  be  out  of  propor- 
tion to  the  small  number  of  patients  treated  in  them. 
The  primary  object  of  providing  Isolation  Hospitals  is, 
however,  to  preveitt  infection  from  spreading  by  the 
seclusion  or  separation  of  persons  suffering  from  infec- 
tious ailments  from  all  who  may  be  susceptible  to  catch 
these  diseases. 

A  few  instances  may  make  this  plain.  The  Delan- 
cey  Hospital,  Cheltenham,  was  erected  and  furnished 
at  an  expenditure  of  ^i  i,  1 2 1  :  2  :  o.  The  total  number 
of  beds  was  32.  During  the  two  years  1879  and  1880 
the  total  cost  of  maintenance,  excluding  certain  items 
for  additional  furnishings  during  the  second  year,  was 
^734  113:2  and  ^731  :  17  :  7,  each  of  these  amounts 
including  a  sum  of  about  ^450  for  wages  and  house- 
keeping, and  an  honorarium  of  ^42  to  the  medical 
officer.  During  these  two  years  7  cases  of  smallpox 
and  53  cases  of  scarlet  fever  were  isolated  in  the  hos- 
pital. The  gross  cost  of  maintenance  was  thus  at  the 
rate  of  ^24  :  8  :  10  per  patient.     The  simple  treatment 


EXPENSE   OE  HOSPITALS  79 

and  maintenance  of  these  60  cases  in  the  hospital 
was,  however,  only  a  small  item  of  the  benefit  that 
accrued.  In  six  years,  by  means  of  the  hospital,  small- 
pox was  prevented  from  spreading  among  the  com- 
munity on  twelve  separate  occasions,  and  the  same 
testimony  is  borne  as  regards  the  isolation  of  scarlet 
fever.  Although  the  cost  for  maintenance  at  the  above 
rate  looks  very  large  for  the  simple  treatment  of  sixty 
cases,  it  is  very  small  in  comparison  to  the  loss  that 
would  result  from  epidemics  of  smallpox  and  scarlet 
fever  among  the  43,000  people  whom  the  hospital 
served.^ 

At  Settle  a  hospital  for  ten  beds  was  provided  in  1878 
by  the  Local  Authority  at  an  expense  of  ;^io6i  :  2  :  6, 
devoted  to  the  improvement  of  an  old  hospital  handed 
over  to  them  by  the  Board  of  Guardians.  The  hospital 
had,  according  to  Dr.  Thorne  Thorne,  been  but  little 
used  until  he  visited  it.  During  the  second  quarter  of 
1879,  three  children  affected  with  scarlet  fever  were 
admitted,  together  with  their  mother.  No  spread  of  the 
fever  took  place,  although  widely  prevalent  in  surround- 
ing districts.  The  simple  treatment  of  this  woman  and 
her  three  children  was  in  itself  of  very  little  good  com- 
pared with  the  prevention  of  an  epidemic  of  the  disease 
in  the  district.  It  was  much  more  economical  for  the 
population  to  provide  for  them  in  a  well-appointed 
hospital  than  to  incur  all  the  expense,  misery,  and 
death  which  might  have  resulted  had   the   epidemic 

1  Supplement  to  Tenth  Report  of  Medical  Officer,  Local  Government  Board, 
pp.  100-102,  reissue  1893. 


So  PREVENTION  OF  EPIDEMICS 

spread  among  them.   Other  instances  Hke  the  above  may- 
be found  by  reference  to  Dr.  Thorne  Thome's  Report.^ 

Wherever  a  hospital  for  infectious  disease  is  pro- 
vided, immediate  advantage  should  be  taken  of  it  as 
soon  as  a  single  case  of  infectious  disease  appears. 
The  case  should  be  at  once  removed  to  it  and  isolated. 
For  this  purpose  the  hospital  must  be  always  kept  in 
perfect  readiness  for  the  admission  of  patients.  Every 
hour's  delay  increases  the  risk  of  the  spread  of  infection. 
If  the  patients  are  not  isolated  until  cases  multiply  and 
the  disease  gets  a  footing,  the  hospital  will  be  of  little 
service  for  the  prevention  of  an  epidemic.  The  disease 
will  spread  in  spite  of  what  is  done,  and  as  far  as  the 
primary  object  of  preventing  disease  is  concerned,  the 
hospital  will  be  an  encumbrance  and  expense.  The 
cost  of  maintaining  the  hospital  will  be  proportionately 
less,  and  the  benefit  resulting  from  it  will  be  propor- 
tionately greater,  according  to  the  perfection  of  the 
facilities  provided  for  the  immediate  admission  of 
patients  to  it,  and  the  advantage  taken  of  these  facilities 
by  the  public. 

The  number  of  beds  that  should  be  provided  in  an 
Isolation  Hospital  for  a  small  town  or  a  rural  district, 
and  the  provision  that  should  be  made  for  the  isolation 
of  separate  infectious  diseases  in  the  same  hospital  at 
the  same  time,  is  rather  difficult  to  determine. 

In  large  towns  the  population  is  crowded,  and  one 
well-equipped  hospital  of  large  size,  and  constructed 

^  Supplement  to  Tenth  Report  of  Medical  Officer  of  the  Local  Government 
Board,  reissued  1893. 


REQUISITE  NUMBER   OF  BEDS 


in  such  a  way  as  to  isolate  different  infectious  diseases 
at  one  and  the  same  time,  may  be  erected  within  easy 
distance  of  the  community.  In  rural  districts  this  is 
out  of  the  question.  In  large  towns  it  has  been  stated 
that  about  i  bed  per  looo  of  the  population  would  be 
sufficient  provision  for  the  isolation  of  infectious  disease 
to  meet  ordinary  emergencies.  This,  however,  will 
not  hold  good  in  the  case  of  rural  districts  or  even 
small  towns. 

The  number  of  beds  necessary  will  be  found  to 
vary  in  different  localities.  In  some  places  there  is 
more  danger  of  infectious  disease  being  frequently 
introduced  by  visitors  and  otherwise,  and  of  the 
outbreak  of  more  than  one  disease  at  the  same  time. 
The  number  of  beds  in  the  hospital  should  also 
to  a  certain  extent  depend  on  the  character  of  the 
house  accommodation  in  the  district.  If  the  houses 
of  many  of  the  inhabitants  are  commodious  and  well 
isolated,  and  so  constructed  that  cases  of  infectious 
disease  may  be  treated  at  home  without  danger  to  the 
inmates  or  to  the  public,  there  is  not  the  same  neces- 
sity for  a  large  number  of  beds  in  the  hospital.  The 
opposite  is  the  case  if  the  houses  are  small  and 
crowded.  In  localities  remote  from  large  centres  of 
population  the  visitations  of  infectious  diseases  are 
as  a  rule  rare,  and  it  is  seldom  that  more  than  one 
disease  breaks  out  at  the  same  time.  In  such  locali- 
ties the  spread  of  infection  is  also  more  slow  than 
in  towns,  owing  to  the  greater  distances  between 
houses,  and  the  less  frequent  communication  between 


82  PREVENTION  OF  EPIDEMICS 

families.  The  spread  of  infection  is,  however,  more 
Hkely  to  get  a  certain  headway  in  such  places.  People 
are  often  taken  unawares,  and  medical  attendance  is 
not  so  convenient  as  in  more  populous  centres.  Several 
members  of  a  family  are  often  taken  ill  before  the 
disease  is  suspected  to  be  of  an  infectious  nature. 
This  must  be  considered  in  reckoning  the  number  of 
beds  that  should  be  provided  in  thinly-populated  rural 
districts.  If  it  were  possible  to  convey  patients  to  a 
hospital  from  very  long  distances  in  rural  districts,  it 
would  probably  be  found  that  the  number  of  beds 
required  would  be  less  than  in  towns.  This,  however, 
is  not  the  case.  However  small  a  population  may  be, 
the  number  likely  to  be  infected  before  the  disease  is 
discovered  must  be  taken  into  consideration.  This  is 
probably  the  reason  why  the  medical  department  of 
the  Local  Government  Board  recommend  that  at  least 
four  beds  should  be  provided  for  villages. 

The  distance  that  patients  suffering  from  infectious 
diseases  may  be  conveyed  with  safety  to  a  hospital  is 
a  matter  for  serious  consideration.  On  this  depends 
the  number  of  hospitals  that  should  be  erected  to 
meet  the  requirements  of  a  population  scattered  over 
a  given  area.  Some  cases  suffering  from  infectious 
diseases  cannot,  without  running  great  danger,  be 
removed  to  a  hospital,  however  near.  Such  cases, 
however,  are  exceptional.  The  great  majority  of 
cases  may  be  conveyed  considerable  distances  during 
the  first  few  days  of  their  illness  without  any  danger. 
Even  in  cases  that  cannot  be  removed  at  once  it  may 


REMOVAL   OF  PATIENTS  83 

be  possible  to  have  them  conveyed  to  a  hospital  at  a 
later  stage  with  safety. 

The  following  evidence  given  before  the  Infectious 
Hospitals  Commission  may  be  of  interest  as  bearing  on 
the  distance  that  patients  may  be  conveyed  to  hos- 
pitals. Dr.  Murphy,^  Medical  Officer  of  Health  for 
the  London  County  Council,  is  of  opinion  that  although 
many  severe  cases  were  conveyed  to  the  London 
Fever  Hospital  a  distance  of  five  or  six  miles,  they 
were  not  aggravated  by  the  conveyance. 

Dr.  Collie,^  late  Medical  Superintendent  to  the 
Homerton  Fever  Hospital,  states  that  nearly  every 
case  of  smallpox  might  be  removed  twenty  miles 
as  safely  as  one ;  and  that  taking  it  broadly, 
the  removal  of  smallpox  patients  is  not  injurious 
to  them,  inasmuch  as  after  carefully  examining  6771 
cases,  he  found  that  out  of  the  total  number  only  one 
was  found  dead  on  arrival,  and  75  died  after  24 
hours'  residence  in  the  hospital,  26  of  these  being  of  a 
malignant  type  (and  therefore  would  have  died  under 
any  circumstances),  21  confluent,  and  2  semiconfiuent. 
They  were  all  brought  in  old  cabs.  He  would 
say  that  16  or  17  miles  would  not  hurt,  and  that  in  pro- 
perly constructed  ambulances,  the  worst  cases  might  be 
brought  from  their  homes  to  the  hospital,  under  proper 
superintendence,  without  hastening  death.  He  had 
frequently  known  cases  conveyed  to  the  hospital  seven 
or  eight  miles,  and  some  of  them  very  serious  cases. 

^  Smallpox  and  Fever  Hospitals  Commission,  Minutes  of  Evidence,  Questions 
3021  and  3024.  2  Question  21 19. 


84  PREVENTION  OF  EPIDEMICS 

Dr.  Thorne  Thorne/  Chief  Medical  Officer  to  the 
Local  Government  Board,  stated  that  his  experience 
covered  a  few  isolated  instances  where  patients  were 
conveyed  a  distance  of  from  eight  to  ten  miles,  and 
many  instances  a  distance  of  from  four  to  five  miles, 
and  that  he  had  not  known  any  evil  effects  following 
on  the  removal,  except  where  the  patient  was  practi- 
cally dying  before  removal. 

Dr.  Bernard,^  late  of  the  Stockwell  Hospital,  how- 
ever, states  that  in  a  bad  case  of  smallpox,  after  the 
disease  has  shown  itself  some  thirty-six  hours,  a  very 
grave  risk  is  run  by  removal. 

Dr.  Littlejohn,^  Consulting  Medical  Officer  for  the 
Board  of  Supervision,  states  that,  generally  speaking, 
for  such  a  district  as  the  three  Lothians  and  the 
adjacent  counties,  the  distance  should  never  be  more 
than  six  miles,  care  being  taken  in  all  cases  to  provide 
a  suitable  attendant,  and  warmth  in  the  shape  of  hot- 
water  bottles,  together  with  restoratives. 

Dr.  Gayton,  Medical  Superintendent  of  the  North 
Western  District  Hospital  of  the  Metropolitan  Asylums 
District  Board,  after  twenty-three  years'  experience  in 
the  hospital  treatment  of  infectious  diseases,  writes  to 
me  as  follows  : — "  In  smallpox,  evidence,  I  think,  exists 
that  removal,  practically  to  any  distance,  after  the  rash 
is  well  out  and  therefore  the  temperature  down,  is  a 
harmless  proceeding,  but  to  do  so  during  the  premoni- 


1  Smallpox  and  Fever  Hospitals  Commission,  Minutes  of  Evidence,  Questions 
1072  and  1073.  2  Questions  3177  and  3179. 

3  Circular,  Public  Health,  No.  VI.,   1S89. 


REMOVAL   OF  PATIENTS 


tory  fever,  with  a  temperature  of  104°  or  105°,  has 
always  appeared  to  me  risky,  as  also  about  the  eighth 
or  ninth  day,  when  the  secondary  fever  has  set  in. 
Of  scarlet  fever  removals,  I  feel  the  shorter  the  dis- 
tance the  better  the  chance  of  recovery,  and  also  that 
in  those  cases  in  which  the  rash  is  '  livid  red,'  as  Fagge 
puts  it,  it  would  be  of  immense  advantage  to  the 
patient  not  to  expose  him  at  all  to  cold  air,  such  as  he 
might  encounter  in  the  winter  months.  Shortly  put, 
my  feeling  would  go  to  treat  cases  where  they  arose, 
and  draw  a  cordon  around  them,  rather  than  send  them 
for  an  excursion  with  temperatures  by  which  the  heart's 
action  is  jeopardised.  Such,  however,  being  impos- 
sible, the  only  rule  to  lay  down  is  to  make  the  journey 
as  short  as  possible.  Enteric  speaks  for  itself,  and 
says  with  no  uncertain  voice.  Leave  me  where  I  am  or 
move  me  with  the  greatest  care  and  the  shortest  dis- 
tance possible.  I  have  seen  cases  perforate  within  an 
hour  after  admission,  presumably  due  to  the  jolting  of 
an  ambulance,  and  to  the  unscientific  handling,  the 
journey  not  having  exceeded  one  mile.  In  reference 
to  diphtheria,  I  see  very  little  objection  to  their 
removal  to  hospital  and  to  some  distance,  if  the 
transfer  is  made  early  and  the  horizontal  position  is 
maintained,  but  to  do  as  is  common  now,  admit  to- 
night and  certify  the  death  to-morrow,  is  clearly  a 
mistake,  and  only  serves  to  credit  us  with  a  mortality 
with  which  we  have  nothing  to  do." 

Dr.  Watt,  Medical  Officer  of  Health  for  the  County 
of  Aberdeen,  states  that  patients  have  been  conveyed 


86  PREVENTION  OF  EPIDEMICS 

in  that  county  a  distance  of  eleven  to  fourteen  miles 
without  any  ill  effects.  I  have  myself  known  several 
cases  of  scarlet,  typhus,  and  typhoid  fevers  having  been 
conveyed  distances  varying  from  eight  to  twelve  miles 
without  any  dangerous  result. 

It  will  thus  be  apparent  that  no  hard  and  fast  rule 
can  be  applied  to  the  conveyance  of  patients  suffering 
from  infectious  diseases.  Every  case  must  be  decided 
on  its  merits.  Not  only  must  the  condition  of  the 
patient  at  the  time  be  considered,  but  the  means  of 
conveyance,  the  state  of  the  roads  and  weather.  It  is, 
however,  probable  that  the  great  majority  of  patients 
suffering  from  any  of  the  common  infectious  diseases 
prevailing  in  this  country  may  be  conveyed,  in  proper 
ambulances  and  with  careful  attendance,  for  consider- 
able distances  without  running  any  risk. 

Dr.  Thorne  Thorne  ^  recommends  that  in  rural  dis- 
tricts the  hospital  should  be  erected  not  more  than  four 
or  five  miles  from  the  more  populous  portions  of  the 
districts  concerned,  and  in  the  case  of  towns  not  more 
than  two  miles.  Such  a  hospital  would  probably 
serve  for  the  isolation  of  patients  from  less  populous 
places  over  an  area  distant  by  road  twelve  to  fifteen 
miles.  To  do  this,  however,  a  well  constructed  carriage 
should  be  provided,  and  the  removal  effected  at  an 
early  stage  of  the  disease,  or  if  this  could  not  be  done 
with  safety  at  the  time,  it  might  be  accomplished  after 
the  patient  recovered  sufficiently  to  bear  the  journey. 

1  Supplement  to   Report  of  Medical  Officer  of  Local   Government   Board, 
1880,  p.  8. 


REMOVAL   OF  PATIENTS  87 

Outbreaks  of  infectious  diseases  almost  invariably  start 
in  the  more  populous  localities.  The  disease,  if 
unchecked,  afterwards  spreads  to  the  outlying  parts. 
A  hospital  would  be  of  more  service  in  prevent- 
ing the  spread  of  disease  to  the  outlying  districts 
than  in  isolating  cases  after  they  had  occurred 
there. 

The  feeling  of  the  population  should  also  to  a 
certain  extent  be  considered  in  settling  the  distance 
patients  are  to  be  conveyed  to  a  hospital.  There  is 
in  some  places  a  feeling  among  many  against  sending 
their  friends  to  a  distance.  This  might  militate  against 
the  use  of  the  hospital  afterwards.  The  nearer  a 
hospital  is  provided,  the  greater  the  chance  of  its  prov- 
ing beneficial.  To  secure  this,  small  burghs  dotted 
over  the  country  should  combine  with  the  Rural 
Authorities  for  hospital  provision.  Under  present 
circumstances  this,  however,  is  difficult  to  accomplish. 
"  LocaP  jealousies,  the  fear  of  expense,  and  other 
causes  have  interfered  with  the  extension  of  this  plan, 
but  the  appointment  of  County  Councils  seems  to  us 
to  afford  an  opportunity  of  removing  the  difficulty. 
Except  in  London  the  County  Councils  have  not  yet 
been  invested  with  many  sanitary  functions.  Parlia- 
ment might  well  increase  their  powers  in  at  least  one 
direction,  by  constituting  them  the  hospital  providing 
authorities  for  the  whole  of  their  respective  counties. 
In  this  way  the  Councils  would  be  placed  on  somewhat 
the  same  footing  as  the  Metropolitan  Asylums  Board 

1  Hospitals  and  Asylums  of  the  World,  Burdett,  vol.  iii.  p.  109. 


PREVENTION  OF  EPIDEMICS 


of  London,  and  probably  with  equally  satisfactory 
results."  County  Councils  might  with  advantage  be 
vested  even  with  greater  powers  in  this  direction  than 
Mr.  Burdett  proposes.  In  dealing  with  infectious 
diseases,  the  wider  the  area  under  one  Local  Authority 
and  the  more  uniform  the  system  adopted  for  the  pre- 
vention of  disease,  if  carried  out  with  energy,  the  greater 
is  the  chance  of  success.  Under  the  present  system 
counties  in  Scotland  are  divided  into  districts  ;  each 
district  is  managed  by  a  separate  Local  Authority  or 
District  Committee,  almost  independent ;  and  dotted 
here  and  there  in  the  districts,  burghs  are  to  be  found, 
entirely  independent  of  County  Councils.  If  one  or  more 
of  these  districts  or  burghs  do  not  provide  sufficient 
means  to  prevent  the  spread  of  disease,  the  surrounding 
area  will  be  continually  infected  by  them.  If,  how- 
ever, County  Councils  were  acting  Local  Authorities 
for  the  prevention  of  the  spread  of  infection  within 
their  respective  counties,  a  uniform  method  would  be 
adopted.  The  stronger  the  public  body  having  con- 
trol of  this  matter,  the  greater  the  chance  of  measures 
being  carried  out  with  efficiency.  Perhaps  in  time  the 
public  may  come  to  see  that  even  a  stronger  board  and 
further  centralisation  is  desirable.^ 

When  it  is  decided  to  build  a  hospital  within  a 
certain  area,  the  site  has  to  be  selected.  If  it  is  of 
great  importance  that  healthy  sites  should  be  chosen 

^  In  the  practice  we  have  not  much  to  learn,  but  in  the  policy  a  great  deal,  in 
the  concentration  of  the  function,  in  the  guidance  of  the  practice,  so  that  there 
may  be  uniform  and  united  action  over  the  entire  area  of  what  ought  to  be  in 
reality  as  in  name  the  community. — Dr.  J.  B.  Russell. 


SITE   OF  HOSPITAL  89 

for  dwelling  houses  intended  to  be  occupied  by  the 
strong  and  vigorous,  it  is  of  still  greater  importance 
that  the  site  for  a  hospital  should  be  healthy,  as  it  is 
intended  to  be  occupied  by  the  sick.  Persons  in  ill 
health  are  more  susceptible  to  all  deleterious  influences 
than  the  healthy.  The  natural  configuration  of  the 
land,  the  geological  formation,  the  soil,  the  under- 
ground and  surface  drainage,  as  well  as  the  relative 
height,  and  the  exposure  to  sun,  rain,  and  wind,  should 
all  be  considered.  A  gentle  slope  at  a  moderate 
elevation  is  preferable  to  the  base  of  a  hill,  a  deep 
valley,  or  a  level  plain.  Dry  gravelly  or  sandy  soil 
is  preferable  to  stiff  soils,  such  as  peat  or  clay, 
likely  to  retain  moisture.  Estuary  shores,  river  banks, 
marshes,  made  soil,  or  ground  likely  to  contain  organic 
matter,  should  be  avoided.  A  hospital  site  should 
have  a  good  exposure  to  the  sun,  and  if  possible  be 
sheltered  from  unhealthy  and  cold  winds.  It  is  also 
desirable  to  have  the  site  in  such  a  locality  that  the 
prevailing  winds  do  not  blow  towards  it  from  any 
unhealthy  area,  or  from  works  which  would  be  likely 
to  have  any  ill  effect  on  the  health  of  the  inmates  of 
the  hospital.  It  should  be  within  reach  of  a  plentiful 
supply  of  pure  water,  and  have  reasonable  facilities  for 
drainage.  "All  these  elements  are  of  importance, 
every  one  in  its  place.  It  is  obviously  of  no  use  to 
build  a  hospital  in  the  best  air  in  the  world  if  neither 
patients  nor  medical  officers  can  get  to  it.  It  is  only 
in  applying  common  sense  to  such  a  question,  and  by 
always  giving  a  preponderance  to  conditions  of  highest 


90  PREVENTION  OF  EPIDEMICS 

importance,  namely,  pure  air  [and  water]  and  space, 
when  the  other  considerations  can  be  at  the  same  time 
reasonably  obtained,  that  the  best  will  be  done  for  the 
sick."  ^ 

The  next  question  for  consideration  is  the  area  of 
a  site  for  a  hospital  with  a  certain  accommodation  and 
of  a  given  size.  This  is  to  a  certain  extent  governed 
by  the  width  of  the  space  that  should  exist  between  the 
hospital  and  the  area  wall,  and  by  the  design  or  plan 
of  the  building  to  be  erected  on  the  site. 

In  the  case  of  an  infectious  hospital  it  is  neces- 
sary, in  order  to  prevent  the  risk  of  infection  from 
spreading  to  the  public  outside  the  grounds,  to  have 
a  certain  space  between  the  buildings  and  the  area 
wall. 

Unless  a  reasonable  space  or  sanitary  zone  is  pro- 
vided, infection  may  be  communicated  to  the  public 
by  means  of  infected  articles  thrown  over  the  wall,  or 
by  currents  of  air  carrying  infected  dust.  What  might 
be  a  safe  distance  may  be  inferred  from  experience 
gained  in  the  case  of  various  infectious  hospitals. 

In  regard  to  the  London  Fever  Hospital,  "the 
occupants  of  houses  in  Theberton  Street,  West,  and  of 
Nos.  II,  12,  and  13  Gibson  Square,  have  lived  within  a 
distance  of  78J  to  84  feet  of  wards  occupied  by  typhus 
fever  from  1863  to  1867,  and  by  scarlet  fever  from  1871 
to  1880.  The  inhabitants  of  No.  4,  5,  6,  and  7  Barford 
Street  have  lived  within  55  feet  of  wards  occupied  by 
typhus   from    1863   to   1867  inclusive,  and   by  scarlet 

1  Florence  Nightingale,  Notes  on  Hospitals,  p.  29. 


SITE   OF  HOSPITAL  91 

fever  from  1871  to  1880.  The  inhabitants  of  Nos.  11 
to  16  Barford  Street  have  Hved  within  a  distance  of 
from  49  to  60  feet  of  wards  occupied  by  typhus  from 
1864  to  1868  inclusive,  and  by  relapsing  fever  from 
1869  to  1 87 1.  From  the  houses  in  Barford  Street 
project  W.C.'s,  which  reduce  the  distance  between  the 
houses  and  the  opposite  wards  to  a  distance  of  between 
36  and  50  feet.  The  shortest  distance  between  a 
house  in  Charles  Street  and  the  opposite  ward  occupied 
by  typhus  and  relapsing  fever  being  29  feet,  while,  if 
the  garden  boundary  be  taken  to  represent  the  nearest 
approach  of  the  inhabitants  to  the  wards,  the  distance 
is  further  reduced  to  22  feet. 

"  The  number  of  cases  treated  during  thirty  years 
was  18,073  typhus.  As  the  result  of  my  inquiry  not 
a  single  case  of  typhus  could  be  heard  of  in  the  houses 
surrounding  the  hospital. 

"  The  total  number  of  relapsing  fever  treated  was 
2078,  but  no  evidence  could  be  found  of  a  single  case 
of  the  disease  having  existed  in  any  of  the  houses. 

"  With  typhoid  6645  were  treated  during  the  thirty 
years,  and  only  five  cases  could  be  heard  of  in  any  of 
the  houses. 

"  As  to  scarlet  fever,  wards  which  contained  for 
years  together  as  many  as  twenty-eight  cases  at  a  time, 
have  existed  within  55  feet  of  inhabited  houses,  without 
any  case  of  this  disease  occurring  in  these  dwellings. 
In  all  the  houses  (ninety-six)  surrounding  the  hospital 
thirty  cases  existed  within  the  memory  of  any  of  the 
occupants.      Dr.    Murphy    believed    that    thirty    cases 


92  PREVENTION  OF  EPIDEMICS 

was  not  in  excess  of  what  might  be  found  in  any 
district  during  the  same  number  of  years  with  a  similar 
class  of  property  in  a  neighbourhood  where  a  fever 
hospital  did  not  exist."  ^ 

At  Newcastle-upon-Tyne  ^  the  hospital  was  within 
34  feet  of  a  poor  and  crowded  neighbourhood,  yet 
although  scarlet,  typhus,  and  enteric  fevers  were 
treated  in  the  hospital,  none  of  these  diseases  spread 
to  the  outside  public,  and  what  is  very  remarkable, 
although  two  elementary  schools  were  one  within  45 
feet  and  the  other  within  100  feet,  the  children  attend- 
ing them  were  not  infected  from  the  hospital  by  any 
of  the  diseases  treated  there. 

Mrs.  Gladstone's  Convalescent  Home  for  Smallpox 
Patients,  according  to  the  late  Dr.  Tripe,  Medical 
Officer  of  Health  for  Hackney,  was  used  for  acute 
cases,  and  was  within  94  feet  of  a  row  of  houses  at  the 
back.  The  windows  at  the  back  were  kept  shut. 
No  case  of  smallpox  whatever  occurred  during  the 
time  the  hospital  was  carried  on,  in  the  row  of 
houses  referred  to.^ 

"  The  City  of  London  Workhouse,  which  overlooks 
the  Homerton  Fever  and  Smallpox  Hospital,  and  is 
distant  from  it,  window  to  window,  only  90  feet,  had 
scarcely  any  case  in  the  epidemics  of  1871  and  1877, 
when  the  disease  was  extremely  prevalent  in  the  sur- 

1  Smallpox  and  Fever  Hospitals  Commission,  Minutes  of  Evidence,  Questions 
3008-3013. 

2  Supplement    to    Report    of  Medical    Officer,    Local    Government    Board, 
1880-81,  pp.  201  and  202. 

3  Smallpox  and  Fever  Hospitals  Commission,  Minutes  of  Evidence,  Question 
576. 


SANITARY  ZONE  ROUND  HOSPITAL  93 

rounding  streets,  although  at  the  time  the  inmates 
were  not  protected  by  revaccination."  ^ 

After,  however,  taking  all  the  evidence  collected 
into  consideration,  the  Infectious  Hospital  Commission 
states  ^ — "  But  we  feel,  so  long  as  it  is  not  proved  that 
'  personal  communication  '  is  adequate  to  the  whole 
spread  of  smallpox,  and  so  long  as  distant  '  atmo- 
spheric dissemination '  is  not  shown  to  be  in  the 
highest  degree  improbable,  so  long  is  it  essential  that 
in  the  construction  and  management  of  smallpox 
hospitals  both  sources  of  danger  should  be  with  the 
utmost  care  guarded  against." 

After  taking  the  history  of  many  hospitals  into 
consideration,  in  so  far  as  the  spread  of  disease  from 
them  is  concerned,  the  Medical  Department  of  the 
Local  Government  Board  have  come  to  the  con- 
clusion that  no  part  of  the  wards  or  outhouses  of  an 
infectious  hospital  should  be  nearer  than  40  feet  to  the 
area  wall.  This,  however,  does  not  include  smallpox. 
A  wider  area  would  probably  be  necessary  for  a  small- 
pox hospital.  From  the  above  facts  it  is  clear  that 
there  is  no  necessity  whatsoever  for  the  erection  of 
Isolation  Hospitals  at  such  inconvenient  distances  from 
habitations  as  is  frequently  the  case.  In  rural  districts 
and  small  burghs,  however,  where  land  is  plentiful  and 
comparatively  cheap,  it  is  better  to  be  on  the  safe  side 
by  building  a  hospital  on  a  roomy  site,  reasonably 
isolated,  but  at  the  same  time  at  a  convenient  distance 

^  Report  of  Smallpox  and  Fever  Hospitals  Commission,  1882,  p.  26, 
^  Ibid.  p.  27. 


94  PREVENTION  OF  EPIDEMICS 

by  a  good  road  from  the  most  populous  part  of  the 
district  to  be  served  by  it. 

In  addition  to  the  sanitary  zone  or  neutral  ground 
all  round  the  hospital  buildings  (which  should  not  be 
entered  by  the  patients  on  one  side  nor  by  the  public 
on  the  other),  the  hospital  buildings  take  up  some  room. 

The  amount  of  ground  covered  by  the  buildings 
must  necessarily  depend  on  the  size  of  the  hospital — 
that  is,  the  accommodation  to  be  provided  in  it.  It 
also  depends  on  the  design,  and  the  design  or  plan 
depends  to  a  large  extent  on  the  number  of  infectious 
diseases  to  be  treated  at  one  time  in  the  hospital.  A 
small  cottage  administering  to  a  couple  of  wards  covers 
much  less  ground  than  a  large  administrative  block 
serving  many  wards.  A  number  of  wards  in  a  many- 
storied  building  covers  much  less  ground  than  the 
same  number  in  one-storied  blocks. 

If  more  than  one  infectious  disease  is  to  be  treated 
at  one  time  in  the  hospital,  it  is  quite  as  important  to 
have  a  safe  space  or  sanitary  zone  between  the  wards 
occupied  by  different  infectious  diseases  as  it  is  to 
have  a  safe  sanitary  zone  between  the  hospital  and 
the  public.  Indeed  it  is  in  some  respects  of  more 
importance.  A  patient  suffering  from  typhoid  fever 
is  quite  as  liable  to  catch  scarlet  fever  as  a  healthy 
person,  and  in  his  weakened  condition  he  is  more 
likely  to  die  if  he  gets  it.  As  I  have,  however, 
previously  endeavoured  to  show,  it  appears  that  some 
infectious  diseases  are  more  liable  to  spread  to  persons 
at   longer  distances  than  others.      The    infection    of 


SANITARY  ZONE  95 


typhus  fever  appears  to  travel  by  means  of  the  atmo- 
sphere in  a  well  ventilated  ward  but  a  short  distance 
from  the  patient.  The  same  is  true  of  diphtheria  and 
typhoid  fever.  Smallpox  and  scarlet  fever,  however, 
travel  farther.  If  the  same  wards  were  to  be  always 
used  for  the  same  diseases  only,  they  might  be  safely 
placed  at  varying  distances  apart,  according  to  the 
distance  infection  might  travel  from  them.  This 
would  necessitate  a  large  number  of  wards,  and  in 
some  cases  would  be  unnecessarily  extravagant.  By 
erecting  one  or  two  blocks  with  two  wards  each,  so 
far  apart  that  the  most  infectious  of  the  ordinary  fevers, 
as  well  as  the  least  infectious,  may,  as  circumstances 
require,  be  isolated  in  them,  this  difficulty  is  to  a 
certain  extent  overcome.  It  is  clear,  therefore,  that 
if  a  sanitary  zone  of  forty  feet  is  necessary  between 
the  wards  and  the  public,  there  should  be  at  least  an 
equal  distance  between  these  ward  blocks  and  those 
occupied  by  persons  suffering  from  other  infectious 
diseases.  In  the  Leamington  hospital,  see  plan,  ap- 
pendix, the  most  infectious  diseases,  i.e.  those  diseases 
likely  to  spread  to  a  distance,  could  at  different  times 
be  isolated  in  the  ward  block  on  one  side,  while  other 
diseases,  such  as  typhus  and  typhoid  or  diphtheria 
might  be  treated  in  different  parts  of  the  isolation 
block  on  the  other  side  of  the  hospital  grounds. 

In  addition  to  this  necessary  zone  some  space  must 
be  allowed,  such  as  airing  courts  for  convalescents, 
drying  green,  as  well  as  space  required  for  the  general 
working  of  the  institution. 


96  PREVENTION  OF  EPIDEMICS 

The  size  of  an  Isolation  Hospital  may  appear  out 
of  proportion  to  the  population  and  the  number  of 
patients  treated  in  it.  This  is  more  particularly 
the  case  in  rural  districts.  To  any  one  who  has  not 
carefully  studied  the  question  it  may  appear  unreason- 
able that  a  hospital  with  several  wards  should  be  built 
apart  on  the  pavilion  style,  say  for  the  accommodation 
of  twenty-four  patients,  when  from  one  end  of  the 
year  to  the  other  there  may  not  be  more  than  twenty- 
four  patients  under  treatment  in  the  whole  building, 
and  at  any  one  time  perhaps  not  more  than  half  a 
dozen. 

Yet  when  it  is  considered  that  in  such  institutions 
not  only  must  there  be  provision  for  the  separation 
of  the  sexes,  but  also  for  at  least  patients  suffering 
from  two  different  infectious  diseases,  as  well  as 
for  the  accommodation  of  nurses  attending  to  the 
different  diseases,  the  reason  for  what  may  appear  to 
be  excessive  accommodation  becomes  apparent.  Not 
only  is  it  necessary  to  have  separate  wards  for  males 
and  females,  suffering  from  say  two  infectious  diseases, 
but  it  is  always  desirable  to  have  a  room  in  which 
doubtful  cases  may  be  isolated  from  the  other  inmates 
until  the  nature  of  the  illness  is  beyond  doubt.^  It  is 
a  very  serious  matter  for  a  patient  suffering  from 
measles    to    be  put    by   mistake    into    a   smallpox   or 

1  In  1890  in  London  85  cases  of  various  diseases  were  certified  as  scarlet 
fever,  74  as  diplitheria,  164  as  enteric  fever,  5  as  continued  fever,  i  as  relapsing 
fever,  2  as  smallpox,  i  as  puerperal  fever,  4  as  typhus  fever,  in  all  336.  All 
these  were  admitted  into  the  hospitals  of  the  Metropolitan  Asylums  Board,  but 
were  found  to  be  suffering  not  from  the  diseases  certified  but  from  various  other 
diseases  mistaken  for  them. — Stat.  Coin.  Rep.  M.A.B.,  1890,  pp.  76-80. 


INFECTIOUS  DISEASES  IN  GENERAL  HOSPITALS     97 

scarlet  fever  ward,  as  he  may  contract  either  of  these 
diseases  immediately  afterwards,  and  while  in  a  weak- 
ened state  is  more  liable  to  die  of  it. 

In  large  well  ventilated  and  well  managed  hospitals, 
it  has  been  found  practicable  on  many  occasions  to  treat 
a  few  cases  of  typhus,  or  typhoid  fever,  or  diphtheria, 
in  a  general  ward  with  non  -  infectious  cases.  If 
this  be  done  the  greatest  care  is  necessary  to  prevent 
such  diseases  from  spreading,  and  even  in  the  best 
hospitals,  and  with  the  greatest  care,  the  system  failed, 
and  is  now  almost  universally  condemned.  It  would 
probably  be  impossible  to  prevent  smallpox,  measles, 
or  scarlet  fever  from  spreading,  if  treated  in  a  ward 
containing  persons  susceptible  to  these  diseases. 

In  a  Report  to  the  Privy  Council  in  1864,  by  Drs. 
Bristowe  and  Timothy  Holmes,  they  state  :  "■  None  of 
our  general  hospitals  receive  smallpox.  Most  of  them 
exclude  scarlet  fever  and  measles.  Several  exclude 
by  rule  all  cases  of  fever,  viz.  :  The  London,  Univer- 
sity College,  Charing  Cross,  and  the  Royal  Free." 
They  also  state  that  many  of  the  London  hospitals 
(viz.  St.  Bartholomew's,  Guy's,  St.  Thomas's,  Middle- 
sex, and  St.  George's),  and  a  few  country  hospitals 
(Bath,  Chichester,  Reading,  and  Oxford),  admit  all 
febrile  diseases  except  smallpox,  and  in  some  scarlet 
fever,  and  that  their  experience  sufficiently  showed 
that  such  diseases  might  be  treated  without  excessive 
danger  in  the  wards  of  general  hospitals.  They, 
however,  stated  that  in  the  great  majority  of  country 
hospitals  such  cases  were  treated  in  separate  buildings 

H 


98  PREVENTION  OF  EPIDEMICS 

or  wards.  They  moreover  admitted  that  the  presence 
of  infectious  disease  in  a  general  ward  was  attended 
by  a  certain  amount  of  risk,  that  typhus  fever  showed 
some  tendency  to  spread  among  the  patients,  and 
that  at  the  time  of  their  visit  to  the  Middlesex 
Hospital  two  patients  were  suffering  from  scarlet  fever 
caught  in  the  hospital.  It  is,  however,  probable  that 
the  absence  of  better  means  for  the  isolation  of  infec- 
tious disease  at  the  time,  affected  the  opinion  of  these 
eminent  physicians,  as  the  following  sentence  indicates  : 
"  Now,  patients  with  scarlet  fever  must  be  treated 
somewhere,  and  we  believe  they  are  much  less  likely 
to  spread  the  disease  in  a  general  ward  than  if  kept  at 
home.  In  a  well-ventilated  and  not  overcrowded 
hospital  the  poison,  even  when  typhus  fever  patients 
are  accumulated,  extends  to  a  very  short  distance 
indeed  around  each  individual  case." 

Sir  William  GulP  states  that  he  remembered  at 
Guy's  Hospital  they  took  in  75  cases  during  the 
Irish  famine,  and  that  they  did  very  well  in  the 
ordinary  wards.  The  disease  did  not  spread.  They 
were  scattered,  and  by  being  scattered,  they  were  not 
infectious. 

Dr.  Howse  states  that  cases  of  typhus  in  former 
epidemics  have  been  placed  and  treated  success- 
fully in  the  large  wards  at  Guy's  amongst 
the  other  patients,  and  that  a  certain  number  of 
cases    of   typhoid    and    diphtheria   are   still    admitted 

1  Smallpox  and  Fever  Hospitals  Commission,  1882,  Minutes  of  Evidence, 
Questions  4470-73. 


INFECTIOUS  DISEASES  IN  GENERAL  HOSPITALS     99 

into    the    general     medical    wards    with     favourable 
results.^ 

I  have  myself,  when  acting  in  the  Fever  and 
Smallpox  Hospitals  at  Homerton,  London,  seen  a 
number  of  cases  of  typhus  treated  in  the  same  ward 
with  about  an  equal  number  of  mixed  non-infectious 
patients,  and  without  any  spread  of  the  disease.  This, 
however,  is  only  possible  under  the  most  favourable 
conditions,  such  as  perfect  ventilation,  abundant  floor 
and  cubic  space,  and  careful  management  and  nursing. 
Even  in  our  best  hospitals,  one  or  more  of  these 
conditions  fail  sometime  or  other,  with  the  result  that 
the  disease  spreads,  as  the  following  facts  show. 
In  1849,2  3  patients  suffering  from  typhus  fever 
in  the  Edinburgh  Royal  Infirmary  gave  the  disease 
to  7  of  38  patients  in  the  ward.  In  St.  Bartholmew's, 
London,  in  1838,  11  visitors,  16  nurses,  and  21  patients 
admitted  for  other  affections,  suffered  from  typhus 
fever.  At  Guy's  in  1862  one  or  two  patients  suffer- 
ing from  typhus  fever  were  admitted  into  a  ward  of 
50  patients,  and  7  took  the  disease.  Infectious  disease 
was  found  to  spread  in  St.  Thomas's  in  1865,  in  the 
Charing  Cross  in  1862,  in  the  Westminster  in  1865, 
and  in  the  Middlesex  in  1867.  In  the  four  years 
1862-65,  407  cases  of  typhus  fever  were  admitted 
into  Guy's,  St.  Thomas's,  German,  King's,  and  the 
London  hospitals  ;  24  patients  who  had  suffered  from 


1  Article  on  "  Hospital  Hygiene,"  Treatise  on  Hygiene  and  Public  Health 
(Stevenson  and  Murphy),  p.  795. 

2  Co7itinued  Fevers,  Dr.  Murchison,  3rd  ed.  pp.  144  and  690. 


PREVENTION  OF  EPIDEMICS 


Other  diseases  and  56  officials  contracted  the  disease, 
103  died,  giving  a  mortahty  of  21.15.  749^  cases 
were  admitted  into  the  London  Fever  Hospital  during 
the  same  period  ;  30  patients  who  had  suffered  from 
other  diseases  and  81  officials  contracted  the  disease, 
141 3  died,  giving  a  mortality  of  18.57.-^ 

In  the  Pendlebury  Hospital,  Manchester,  In  1877, 
the  total  admissions  were  560.  Of  these  183  suffered 
from  infectious  diseases ;  1 8  patients  in  the  general 
wards  contracted  scarlet  fever,  6  patients  admitted  for 
measles  contracted  scarlet  fever,  and  3  admitted  with 
scarlet  fever  contracted  measles.  In  1878,  of  901 
patients  admitted  204  were  infectious  cases ;  14 
patients  in  the  ordinary  wards  contracted  scarlet  fever 
and  3  measles,  and  8  patients  under  treatment  for 
measles  contracted  scarlet  fever.  In  1879,  of  859 
patients  admitted  136  were  infectious  cases;  12 
patients  in  the  ordinary  wards  contracted  scarlet  fever, 
and  3  contracted  measles.  In  1880,  of  840  cases 
admitted  131  suffered  from  infectious  diseases;  12 
patients  in  the  general  wards  contracted  scarlet  fever 
and  3  measles,  while  3  patients  who  had  suffered  from 
measles  contracted  scarlet  fever,  and  4  patients  who 
had  suffered  from  scarlet  fever  caught  measles.^ 

In  this  hospital  the  infectious  cases  admitted  were 
suffering  from  "fever,"  measles,  or  scarlet  fever,  and 
were  treated  in  one  special  fever  ward.  Dr.  Thorne 
Thorne  states   that   "this   hospital   is   constructed  on 

1  Murchison,  Continued  Fcve7-s,  3rd  ed.  pp.  691-692. 

2  Supplement  to  Tenth  Annual  Report  of  the  Local  Government  Board,  p. 
184. 


INFECTIOUS  DISEASES  IN  GENERAL  HOSPITALS  loi 

the  most  modern  principles,  and  subject  to  a  stringent 
administration  .  .  .  that  fever  patients  In  their  pass- 
age from  the  fever  reception  room  to  the  fever  ward 
do  not  pass  within  45  feet  of  any  of  the  wards 
occupied  by  patients  .  .  .  that  It  would  be  difficult  to 
find  any  general  hospital  where  the  reception  of 
infectious  cases  Is  subjected  to  stricter  regulations 
with  a  view  to  their  Isolation,  and  that  there  is  prob- 
ably none  where  the  conditions  affecting  the  patients 
themselves  are  more  conducive  to  this  end." 

One  is,  therefore,  forced  to  the  conclusion  that 
infectious  diseases  should  not  be  treated  In  a  general 
ward,  or  even  in  a  separate  ward,  In  connection  with 
a  general  hospital,  and  also  that  It  is  necessary  to 
have  separate  wards  for  as  many  Infectious  diseases 
as  are  to  be  treated  at  one  time  in  an  Isolation 
Hospital,  that  these  wards  should  be  at  safe  distances 
the  one  from  the  other,  and  that  the  greatest  care  is 
necessary  both  in  designing  and  administering  such 
hospitals  to  prevent  patients  suffering  from  one  disease 
from  Infecting  those  suffering  from  another  Infectious 
disease. 

Authorities  agree  as  to  the  necessity,  in  all 
infectious  hospitals,  of  having  the  administrative 
building  detached  at  a  safe  distance  from  the  wards  ; 
of  having  ward  blocks,  Intended  for  different  diseases, 
one  storey  high,  detached,  and  at  a  safe  distance  the 
one  from  the  other,  and  of  having  certain  outhouses, 
such  as  laundry,  stores  for  infected  clothing,  disinfect- 
ing chamber,  mortuary,  ashpit,  coal-store,  etc.,  erected 


PREVENTION  OF  EPIDEMICS 


at  a  safe  distance  both  from  the  wards  and  from  the 
administrative  building.  The  object  that  should  be 
aimed  at  is  to  render  the  isolation  of  the  sick  as  com- 
plete as  possible,  not  only  from  the  danger  of  infection 
from  other  diseases,  but  also  from  all  sources  of  foul 
air.  The  patients  and  attendants  should  be  guarded 
against  air,  food,  or  water  being  contaminated  in  the 
administrative  building,  as  well  as  against  air,  food, 
water,  or  clothing,  or  any  other  material,  being  con- 
taminated by  effluvia  or  specific  infectious  agents  in 
the  outhouses,  or  arising  from  the  sick  in  the  same 
ward,  or  in  any  other  ward  within  the  hospital 
grounds.  In  order  to  prevent  communication  be- 
tween the  inmates  of  an  Isolation  Hospital  and  the 
public,  the  hospital  grounds  should  be  surrounded  by 
a  stone  wall  at  least  6  feet  6  inches  high. 

"  The  constituents  of  the  atmosphere  intermingle 
chiefly  in  a  horizontal  direction,  hence  the  necessity  of 
combating  by  increased  space  the  effect  of  contact,  and 
of  the  proximity  which  constitutes  crowding,  and  the 
influence  which  is  communicated  from  patient  to 
patient,  ward  to  ward,  and  from  one  building  to 
another.  To  strive  successfully  against  contagious 
influences  not  only  needs  an  increase  of  the  cubic 
space  allowed  to  each  sick  person,  but  in  addition, 
and  above  all,  an  increase  of  superficial  area.  .  .  . 
For  similar  reasons  the  multiplication  of  stories  is 
contraindicated,  as  each  of  them  generates  a  more 
or  less  vitiated  atmosphere.  .  .  .  Buildings  com- 
pletely   isolated,    and    all    having    the    same    aspect 


ARRANGEMENT  OF  BUILDINGS—REASONS  FOR     103 

freely  exposed  to  light,  and  to  the  action  of  the 
wind  and  rain,  should  be  placed  on  a  single,  or  in 
parallel    lines,   at    intervals   of   loi    to    119   yards,   so 

as    to  secure  effective  separation   and   external   aera- 

i*      "  1 
tion. 

Dr.  Wylie,^  of  New  York,  states  that  "experience 
and  science  agree  in  showing  that  widely -detached 
one-storey  wards  allow  the  most  thorough  ventilation, 
and  therefore  the  smallest  chance  for  the  accumulation 
of  infectious  particles.  They  make  classification  of 
cases  easy  and  natural.  They  require  less  vigilance, 
dust  and  foul  air  find  fewer  lurking  holes  and  chan- 
nels, cleanliness  and  ease  of  supervision,  as  well  as 
fresh  air,  are  more  readily  secured." 

Miss  Florence  Nightingale  states :  "  The  most 
healthy  hospitals  have  been  those  on  one  floor  only, 
and  this  because  they  require  less  scientific  knowledge 
and  practical  care  in  ventilation.  .  .  .  There  are  in- 
stances in  which  the  mortality  of  patients  on  upper 
floors  has  been  higher  than  of  those  on  the  floors 
below.  ...  If  another  floor  is  added  a  community  of 
ventilation  exists  between  the  ward  below  and  the 
ward  above  by  the  common  staircase,  and  by  filtration 
of  air  upwards  through  the  floor."  ^ 

"  The  mode  of  construction  in  hospitals  is,  it  is  pre- 
sumed, to  be  determined  by  that  which  is  best  for  the 


1  Extract  from  Conclusions  of  Surgical   Society  of  Paris,  Mouatt  and  Snell's 
Hospital  Cojtstj-uction  and  Management,  pp.  21  and  22. 

2  "  Hospitals,    their  History,   Organisation,    and  Construction,"  see   Buck's 
Hygiene  and  Public  Health,  p.  753,  vol.  i. 

2  Notes  on  Hospitals,  Miss  Florence  Nightingale,  p.  58. 


I04  PREVENTION  OF  EPIDEMICS 

recovery  of  the  sick.  If  any  other  consideration  is 
taken,  such  or  such  a  percentage  of  mortaHty  is  to  be 
sacrificed  to  that  other  consideration,  but  it  so  happens 
that  the  safest  for  the  sick  is  in  reaHty  the  most  eco- 
nomical mode  of  construction."  ^  .  .  .  "  The  first  prin- 
ciple of  hospital  construction  is  to  divide  the  sick 
among  separate  pavilions.  By  a  hospital  pavilion  is 
meant  a  detached  block  of  building  capable  of  contain- 
ing the  largest  number  of  beds  that  can  be  placed 
safely  in  it,  together  with  suitable  nurses'  rooms,  ward 
sculleries,  lavatories,  baths,  water-closets,  all  complete, 
proportioned  to  the  number  of  the  sick,  and  quite  uncon- 
nected with  any  other  pavilion  of  which  the  hospital 
may  consist,  or  with  the  general  administrative  offices, 
except  by  light  airy  passages  or  corridors.  A  pavilion 
is  indeed  a  separate  detached  hospital  which  has,  or 
ought  to  have,  as  little  connection  in  its  ventilation 
with  any  other  part  of  the  hospital  as  if  it  were  really 
a  separate  establishment  miles  away." 

Sir  Douglas  Gal  ton  states  that  "it  may  be  taken 
as  accepted  as  a  rule  that,  so  far  as  the  sick  are  con- 
cerned, they  would  be  better  placed  in  wards  all  on 
one  floor  opening  out  of  a  common  corridor,  and  if  the 
land  is  cheap,  and  the  site  fairly  level,  it  is  probable 
that  such  an  arrangement  might  be  more  economical 
than  building  two-storied  buildings." 

Dr.  Caspar  Morris  -  and  Messrs.  Mouatt  and 
Snell  quote  the  opinions  of  the   Chirurgical   Society 

1  Notes  on  Hospitals,  Miss  Florence  Nightingale,  p.  59. 

2  Hospital  Consti-iution  and  Management  (John  Hopkins),  p.  181. 


HOSPITALS  SITE-PATIENTS  PER  ACRE  105 

of  Paris  that  not  less  than  64  yards  per  patient 
should  be  allowed  (non-infectious  hospitals  evidently- 
considered).  Dr.  Stephen  Smith  ^  remarks  that 
"where  grounds  are  ample  ,  .  .  there  is  no  reason 
why  the  number  should  exceed  forty  persons  per  acre, 
as  a  general  average.   ..." 

"  An  ideal  site  for  an  hospital  would  be  where  the 
conditions  of  soil,  subsoil,  drainage,  water  supply,  and 
all  surroundino^s  were  most  free  from  local  causes  of 
impurities,  and  where  there  were  fewest  buildings  and 
habitations  to  exclude  or  intercept  air  and  light,  or 
to  be  themselves  active  agents  in  the  creation  of 
causes  of  unhealthiness,  such  as  factories,  workshops," 
etc. 

According  to  Dr.  Francis  H.  Brown, ^  "  a  hospital 
should  be  surrounded  by  a  zone  of  aeration  unen- 
cumbered with  buildings,  etc.,  to  a  distance  of  twice 
its  height.  "  That  building  makes  the  best  hospital 
which  is  situated  high,  dry,  and  detached,  with  suf- 
ficient doors  and  windows  for  cross  ventilation,  open 
fireplaces,  secure  roofs  and  walls,  easy  access,  lofty, 
and  of  moderate  size." 

Dr.  Thorne  Thorne  ^  states  :  "  I  have  been  led  to 
regard  an  elevated  site  on  a  gentle  slope,  and  on  a  dry 
soil  where  the  free  circulation  of  air  about  the  hospital 
buildings    was    not    interfered    with,    and    where   an 

^  Hospital  Constrttction\and  Management  (John  Hopkins),  p.  284. 
2  Hospital  Construction  and  Managemejit,  p.  22,  Messrs.  Mouatt  and  Snell. 
2  Buck's  Hygiene  and  Ptiblic  Health,  vol.  i.  p.  738. 

*  Report  of  Medical  Officer,  Local  Government  Board  Supplement,  1880- 
1881,  pp.  8  and  11. 


io6  PREVENTION  OF  EPIDEMICS 

abundant  and  wholesome  water  supply,  with  reason- 
able facilities  for  drainage,  were  available,  as  having 
distinct  advantages  over  sites  differently  circum- 
stanced. .  .  .  Amongst  the  hospitals  visited,  and 
where  these  several  necessary  conditions  have  been 
fulfilled,  I  would  name  those  in  Bradford,  Cheltenham, 
Tunbridge,  and  Warrington  Urban  Districts,  in  the 
Berkhampstead  and  Solihull  rural  districts,  and  that 
belonging  to  the  Weymouth  Port  Sanitary  Authority. 
In  none  of  these  instances  does  the  number  of  patients 
per  acre  exceed  twenty." 

"  It  is,  as  a  rule,  undesirable  to  select  any  site 
which  is  less  than  some  two  acres  in  extent,  and  even 
then  regard  should  be  had  to  the  need  for  extension  of 
hospital  buildings,  whether  for  temporary  purposes,  or 
owing  to  increase  of  population."^ 

Some  appear  to  be  of  opinion  that  infectious 
diseases  may  be  prevented  from  spreading  by  means 
of  temporary,  movable  huts,  and  in  some  districts  in 
rural  Scotland  these  have  already  been  provided. 
Corrugated  iron  and  wooden  buildings,  constructed 
in  sections  and  ingeniously  made  for  packing,  are 
supplied  by  various  firms  for  this  purpose.  These 
buildings  can  be  erected,  taken  down  after  use,  packed 
and  transferred  to  another  locality  for  re-erection. 

The  advantages  claimed  for  such  buildings  are 
that  the  initial  expense  is  less,  while  the  district  will 


^  Paper  read  in  the  Architectural  Section  of  the  Seventh  International 
Congress  of  Hygiene  and  Demography  held  in  London,  August  1891  (Dr.  Thorne 
Thorne). 


TEMPORARY  HUTS  107 

be  equally  well  served.  Instead  of  patients  being 
conveyed  long  distances  to  the  hospital,  the  hospital 
is  to  be  brought  to  them. 

The  scheme  at  first  sight  looks  well  both  from  a 
financial  and  medical  point  of  view.  Against  it,  how- 
ever, must  be  set  the  expense  of  demolition,  packing, 
conveyance,  and  re-erection  of  such  a  building  every 
time  it  is  moved,  the  additional  wear  and  tear  of  the 
structure,  the  difficulty  of  providing  a  building  which 
will  give  sufficient  shelter,  and  afford  the  necessary 
comfort  and  safety  for  isolation,  and  for  the  recovery 
of  the  sick  in  our  climate,  as  well  as  the  delay  which 
will  necessarily  take  place  in  selecting  a  fresh  site  in 
every  locality  where  it  is  proposed  to  have  it 
temporarily  erected.  An  ambulance  carriage  will  be 
required  whether  the  hospital  is  movable  or  stationary, 
as  it  cannot  always  be  erected  within  a  short  distance 
of  all  the  infected  families. 

The  primary  use  of  an  Isolation  Hospital  of  any 
kind,  whether  movable  or  fixed,  is  to  prevent  the 
spread  of  disease  by  providing  means  for  the  immediate 
seclusion  of  such  cases  as  may  occur.  The  delay  which 
will  necessarily  take  place  in  getting  a  movable  hut 
ready  for  the  reception  of  patients  will  allow  the  disease 
time  to  spread. 

Even  in  thinly  populated  localities  permanent 
structures  should  be  provided,  and  be  always  kept  in 
readiness  for  the  admission  of  patients.  In  remote 
localities  where  outbreaks  of  disease  are  rare,  and 
where  two  infectious  diseases  but  seldom  break  out  at 


io8  PREVENTION  OF  EPIDEMICS 

one  and  the  same  time,  it  will  suffice,  at  any  rate  to 
begin  with,  to  make  provision  for  the  isolation  of  one 
disease  in  the  hospital.  The  current  expense  will  also 
be  less,  owing  to  the  fact  that  nurses  need  not  be 
permanently  employed  in  such  hospitals. 

In  addition  to  pollution  by  the  infectious  agents  of 
disease,  an  Isolation  Hospital  is  liable  to  contamina- 
tion by  the  effluvia  from  the  bodies,  the  breath,  and 
excretions  of  the  patients,  as  well  as  from  foul  linen, 
bedclothes  discharges  from  sores,  etc.  etc.  It  is  there- 
fore essential  to  construct  and  furnish  a  hospital  of 
such  material  as  will  not  absorb  noxious  effluvia,  and 
to  provide  sufficient  floor  and  cubic  space,  a  plentiful 
supply  of  water,  perfect  ventilation,  proper  arrange- 
ments for  the  removal  of  excretions  and  dirt  in  its 
various  forms,  and  for  disinfection  and  washing. 
Provision  should  also  be  made  for  the  safe  isolation 
of  nurses  and  servants  attending  to  each  disease,  and 
for  their  healthy  accommodation  whether  on  or  off 
duty.  There  must  also  be  proper  and  safe  means  for 
the  cooking  and  distribution  of  food,  as  well  as  for  the 
storage  of  food,  clothes,  medicines,  and  other  necessaries. 
At  the  same  time  the  whole  building  should  be  designed 
in  such  a  way  as  to  render  the  efficient  discharge  of 
their  duties  as  convenient  as  possible  for  all  engaged 
in  the  hospital. 

An  Isolation  Hospital  of  whatever  size  should 
consist  of — ( I )  A  detached  administrative  block  or  build- 
ing, containing  the  kitchen  with  its  necessary  stores, 
etc.,  and   the  living  and  sleeping  apartments  of  the 


ARRANGEMENT  OF  BUILDINGS  109 

hospital  staff;  (2)  Wards,  with  their  appendages 
in  separate  pavilions,  or  blocks,  or  cottages,  at  safe 
distances,  providing  for  the  separation  of  the  sexes, 
and  for  patients  suffering  from  different  diseases ; 
(3)  Outhouses  such  as  laundry,  stores,  disinfecting 
apparatus,  mortuary,  etc. 

The  administrative  block  should  minister  to  the 
whole  hospital  (excepting  perhaps  when  smallpox^  is 
isolated).  It  should  at  least  be  forty  feet  from  the 
wards.  No  food,  clothing,  earthenware,  furniture,  or 
anything  else  should  get  mixed  in  the  work  of 
administration.  The  block  or  ward  used  for  one 
disease  should  be  at  least  forty  feet  from  the  ward 
occupied  by  patients  suffering  from  any  other  disease.^ 
When  a  patient  is  admitted,^  he  should  be  sent  into 
the  receiving  room  of  the  block  set  apart  for  his 
disease.  If  it  is  a  matter  of  doubt  whether  the  patient 
is  suffering  from  an  infectious  disease,  or  if  infectious, 
what  disease,  he  should  be  sent  to  an  isolation  ward 
until  the  nature  of  the  disease  becomes  more  apparent. 
If  there  is  no  doubt  about  the  case,  it  should  be  sent 
to  the  ward  intended  for  it.  The  patient,  if  able  to 
bear  it,  should  be 'undressed  in  the  bath-room,  bathed, 
provided  with  clean  night-dress,  and  put  to  bed.     The 

1  The  nurses  attending  smallpox  should  be  accommodated  in  rooms  apart 
from  the  general  administrative  building.  If  sleeping  in  the  administrative  build- 
ing, they  should  change  their  clothes  and  take  a  bath  on  going  off  duty. 

^  Such  diseases  as  typhoid,  diphtheria,  and  typhus  fever  might,  with  care  on 
the  part  of  the  attendants,  be  treated  without  danger  in  wards  separated  by  a  shorter 
distance  than  forty  feet. 

3  Every  case  of  infectious  disease  removed  to  a  hospital  should  be  certified 
by  a  medical  attendant,  and  the  consent  of  the  friends  or  relatives  obtained  if 
possible. 


no  PREVENTION  OF  EPIDEMICS 

clothes  should  immediately  be  put  into  the  disinfecting 
chamber,  and  after  being  disinfected  and  washed  stored 
in  a  cupboard  or  apartment  provided  for  it.  If 
necessary  the  clothes  should  be  destroyed.  The 
ambulance  should  be  at  once  disinfected. 

All  bedclothes,  linen,  towels,  etc.,  should  be 
marked  separately  for  each  disease,  stored  in  its 
special  department,  and  on  no  account  used  in  any 
other  part  of  the  building.  Care  should  be  taken 
to  prevent  the  clothes  from  getting  infected  in  the 
laundry.  The  clothes  from  each  department  should 
be  thoroughly  disinfected  before  being  taken  to  the 
laundry,  and  the  laundry  so  constructed  that  it  can- 
not retain  infection  and  become  a  source  of  danger 
to  the  hospital.  When  dry  the  clothes  should  at 
once  be  brought  back  and  stored  in  their  special 
department. 

All  earthenware,  spoons,  knives,  forks,  feeding 
glasses,  and  other  articles,  should  be  of  different 
patterns  for  each  disease,  or  differently  marked  for 
each  department,  and  washed  and  stored  there.  The 
main  articles  of  food  should  be  conveyed  to  each 
block  in  utensils  belonging  to  the  administrative 
department  by  a  person  not  engaged  in  any  of  the 
wards,  and  there  transferred  into  utensils  belonging 
to  that  block. 

The  nurse  should  keep  to  one  disease  exclusively 
when  on  duty.  She  should  wear  a  loose  wrapper 
and  leave  it  in  the  apartment  provided  for  it  when 
going  away.      She  should  wash  her  hands  well  with 


ARRANGEMENT  OF  BUILDINGS  in 

some  efficient  disinfectant,  and  if  necessary  take  a 
bath.  Her  bedclothes,  linen,  etc.,  should  be  kept  in 
her  own  bedroom  and  not  mixed  with  those  of  a 
nurse  attending  any  other  disease.  When  a  patient 
is  to  be  discharged  and  there  is  not  a  special 
discharging  room,  the  bath  and  bath  -  room  should 
be  rendered  as  free  as  possible  from  infection,  and  it 
should  be  so  placed  that  after  being  bathed  and 
dressed  the  patient  need  not  return  again  to  the 
infected  ward.  In  the  hospital  ships,  Atlas  and 
Endymion,  in  1881  a  patient  before  being  discharged 
was  taken  from  the  Atlas,  on  which  he  was  treated,  by 
a  drawbridge  to  the  Endymion.  He  entered  a  bath- 
room, and  after  taking  his  bath  he  went  by  a  door 
into  a  passage  leading  into  the  dressing-room.  In 
this  passage  a  large  carbolic  spray  was  playing.  In 
the  dressing-room  he  found  a  new  suit  provided  for 
him.  After  dressing  he  was  sent  home  direct  from 
the  Endymion  by  means  of  conveyances  provided  by 
the  Metropolitan  Asylums  Board. 

In  the  Blegdam  Hospital,  Copenhagen,  "two 
rooms  are  provided  for  visits  to  convalescent  patients. 
The  wall  of  separation  is  furnished  with  a  window  and 
a  grille.  The  patient  is  in  one  room  and  his  visitor 
in  the  other,  and  they  can  see  and  converse  but  cannot 
touch  one  another.  The  access  to  the  patient's  room 
is  quite  separate  and  distinct  from  that  to  the  visitor's 
room.^ 

In   the   Belvidere   Hospital,    Glasgow,   undressing 

1  Burdett,  Hospitals  and  Asylums  of  the  World,  vol.  iv.  pp.  2S3  and  284. 


112  PREVENTION  OF  EPIDEMICS 

closets,  bath-rooms,  and  a  dressing-room  are  provided 
at  a  distance  from  the  wards,  for  patients  to  be 
discharged. 

Often  but  Httle  attention  is  paid  to  all  these  con- 
siderations in  designing  an  infectious  hospital,  but  if 
not  attended  to,  disease  is  liable  to  spread  not  only 
among  the  inmates,  but  from  them  to  the  public 
outside.  It  is,  however,  practically  impossible  to 
provide  all  these  conveniences  in  small  hospitals  in 
rural  districts. 

Such  hospitals,  however,  are  in  many  ways  different 
from  larofe  institutions  in  the  towns.  In  rural  districts 
the  hospital  is  often  empty.  It  is  very  rarely  full. 
Although  provision  may  be  made  in  it  for  more  than 
one  disease,  it  is  very  rarely  that  many  patients 
suffering  from  even  two  diseases  are  isolated  in  it 
at  the  same  time. 

I  shall  be  able  to  show  further  on  that  a  room 
or  ward  used  for  the  isolation  of  one  disease  may,  by 
careful  disinfection,  be  afterwards  rendered  perfectly 
safe  for  the  treatment  of  another  disease.  If,  there- 
fore, a  small  hospital,  instead  of  two  large  wards, 
consists  of  a  number  of  small  rooms  sufficiently 
separated,  more  than  one  disease  may  be  isolated 
in  it  at  one  and  the  same  time,  and  a  room  can 
always  be  kept  for  doubtful  cases.  An  empty  room 
may  be  used  as  a  discharging  room,  or,  if  the  bath-  , 
room  is  placed  in  a  suitable  position,  it  can  be 
sufficiently  disinfected  to  serve  as  a  discharging  room 
when   necessary.      "  The   larger  the  wards   the  more 


ARRANGEMENT  OF  BUILDINGS  113 

difficult  it  is  to  secure  the  isolation  and  classification 
of  patients,  and  the  smaller  the  wards  the  greater  is 
the  labour  and  cost  of  supervision  and  attend- 
ance. 

1  Hospital  Construction  and  Alanagement,  Dr.  Billing  (John  Hopkins),  p.  40. 
With  small  wards  less  expense  is  incurred  in  firing  and  lighting,  when  only 
one  or  two  patients  are  isolated. 


CHAPTER    VI 

Hospital  Construction 

The  administrative  block  should  in  size  and  arrange- 
ment be  in  proportion  to  the  size  of  the  hospital,  the 
number  of  patients  and  others  to  be  served  by  it,  and 
the    staff   to    be    accommodated    in    it.       Authorities 
appear  to   be  unanimously  of  opinion  that  whatever 
may  be  the  size  or  the  material  of  which  the  wards  are 
built,   the   administrative  building  should    be    a   per- 
manent, well-built  structure.      In  growing  towns  and 
rural  districts  it  should  as  a  rule  provide  accommoda- 
tion   and    conveniences    in    excess   of  the    immediate 
requirements.     This  is  not  only  desirable,  in  order  to 
save  expense  should  the  hospital  at  any  time  be  en- 
larged, owing  to  increase  of  the  population,  but  also  to 
provide  such  extra  accommodation  as  may  be  found 
necessary   for  nurses   during  any   sudden   emergency 
from  an  exceptional  outbreak  of  disease.     The  adminis- 
trative building  should  be  erected  within  the  hospital 
grounds   at   a  safe  distance  from  the  wards  and  out- 
houses (at  least  forty  feet),  and  it  should  be  so  placed 
as  to  be  convenient  for  the  wards,  yet  so  situated  that 
persons,  such  as  visitors  and  friends  of  patients,  may 


ADMINISTRATIVE  BLOCK  115 

enter  it  from  the  front  gate  without  coming  within 
reach  of  infection  from  the  wards  or  any  other  part  of 
the  building.  In  our  cHmate  it  is  generally  desirable 
to  have  it  connected  with  the  wards  by  a  roofed 
passage  or  corridor,  open  as  much  as  possible  on  both 
sides. 

The  kitchen,  with  its  accessories,  such  as  stores, 
larder,  pantry,  etc.,  should  be  conveniently  placed  for 
the  wards,  and  in  size  and  arrangement  should  be  pro- 
portionate to  the  requirements  of  the  hospital  as  a 
whole.  A  room  should  be  provided  for  the  medical 
officer,  in  which,  if  necessary,  medicines  and  other 
appliances  may  be  kept.  There  should  also  be  a 
store  for  linen  used  in  the  administrative  building,  in 
which  new  clothes  and  other  articles  might  be  kept 
until  required  in  the  wards.  Such  articles,  however, 
when  once  used  should  not  be  returned  to  this  store, 
but  kept  in  places  provided  in  the  special  block  or 
department  to  which  they  have  been  sent.  In  most 
other  respects  the  administrative  cottage  should  be 
built  and  arranged  according  to  the  rules  and  regula- 
tions in  regard  to  water  supply,  drainage,  ventilation, 
cubic  space,  and  other  conveniences,  which  govern  the 
construction  of  good,  modern  dwelling-houses  of  the 
same  size. 

Wards. — Of  all  parts  of  a  hospital  building  the 
wards  are  the  most  important.  Their  structure  and 
arrangement,  therefore,  deserve  the  greatest  care  and 
consideration.  The  reasons  for  this  have  already  been 
given.     This  is  necessary  even  in  the  case  of  wards 


ii6  PREVENTION  OF  EPIDEMICS 

intended  for  non-infectious  diseases,  but  it  is  much  more 
so  in  Isolation  Hospitals,  where,  in  addition  to  the 
various  deleterious  emanations  which  are  generated  in 
persons  suffering  from  non-infectious  ailments,  specific 
agencies  are  liable  to  accumulate  and  to  contaminate  the 
air  as  well  as  the  building  and  furniture.  The  whole 
hospital  should  be  guarded  against  the  absorption  and 
retention  of  these  emanations  and  agents  of  disease, 
but  more  particularly  the  wards,  for  these  are  exposed 
to  unhealthy  influences  in  a  more  concentrated  state, 
and  more  continuously  than  the  other  parts  of  the 
building.  I  have  already  shown  that  various  impurities 
have  been  found  floating  about  in  the  air  of  hospital 
\vards  and  on  and  within  the  walls  ;  that  bacteriologists 
have  conclusively  proved  that  the  organisms  of 
disease  are  able  to  live  outside  the  human  body  for 
an  indefinite  period,  and  may  retain  their  power  of 
infection ;  and  that  other  observers  in  the  field  of 
preventive  medicine  have  proved  the  occurrence  of 
outbreaks  of  infectious  diseases  as  the  result  of  in- 
fection remaining  in  and  about  dwellings  for  varying 
periods. 

In  small  hospitals  such  as  those  under  considera- 
tion, each  ward  block,  pavilion,  or  cottage,  should  at 
least  contain  two  wards,  one  for  males  and  one  for 
females,  and  a  nurse's  duty-room,  as  well  as  proper 
provision  for  cleanliness,  bathing,  and  for  the  disposal 
of  excretions.  In  some  cases  it  is  desirable  to  have 
more  than  two  wards  in  one  block  in  order  to  allow  of 
the  separation  of  a  doubtful,  a  troublesome,  or  a  dying 


WARDS  117 

case,  from  the  others,  or  for  the  accommodation  of  a 
paying  patient. 

The  ground  on  which  a  hospital  paviHon  is  built 
should  be  covered  with  concrete  or  asphalt,  and  the 
foundation  built  in  arches  so  as  to  allow  the  floors  of 
the  wards  to  be  elevated  from  the  base  by  six  to  eight 
feet.^ 

This  has  been  done  in  the  hospital  at  Ealing  ^  and 
other  places.  It  prevents  the  possibility  of  the  soil 
immediately  under  the  wards  from  becoming  infected 
by  the  accumulation  of  filth,  or  by  soakage  from 
drains,  or  in  any  other  way.  When  this  is  not  done 
the  ground  should  be  drained  and  covered  with  a  thick 
layer  of  concrete.  A  damp-proof  course  should  be 
laid  on  the  foundation,  and  the  space  under  the  floor 
should  be  properly  ventilated. 

The  position  of  the  nurses'  duty-room  and  the  other 
ward  accessories,  such  as  bath  and  water-closets,  will 
be  seen  to  vary  slightly  in  different  well-constructed 
hospitals,  by  reference  to  the  plans  appended. 

The  materials  of  which  ward  pavilions  are  built  also 
vary.  Brick,  stone,  concrete,  wood,  corrugated  iron, 
are  used  in  different  localities.  Most  authorities 
appear  to  be  agreed  as  to  the  superiority  of  permanent 
brick  or  stone  buildings  for  localities  that  can  afford  to 
bear  the  expenditure.  It  is  doubtful,  considering  the 
wear  and  tear  and  the  extra  expense  of  the  upkeep  of 
buildings  constructed  of  less  enduring  material,  whether 

1  Francis  H.  Brown,  M.D.,  Buck's  Hygiene,  vol.  ii.  p.  747. 
2  See  Plan,  Appendix. 


ii8  PREVENTION  OF  EPIDEMICS 

Stone  or  brick  would  not  be  cheaper  for  all  localities, 
more  particularly  as  the  payment  may  be  extended 
over  a  long  series  of  years.  Some  authorities,  how- 
ever, appear  to  be  in  favour  of  wooden  buildings.  Dr. 
Francis  Brown  of  New  York  states  that  the  plan  which 
commended  itself  most  favourably  to  medical  men  of 
late  years  in  establishing  a  hospital,  whether  of  large 
or  small  dimensions,  has  been  to  build  it  of  detached 
wooden  pavilions,  with  an  administrative  building  of 
more  permanent  material,  and  that  it  cannot  be 
questioned  that  wooden  buildings  "bring  the  patient 
nearer  the  condition  of  nature,"  that  such  an  arrange- 
ment is  more  satisfactory  on  the  ground  of  expense, 
and  that  a  barrack  hospital  is  more  speedily  and  easily 
erected.^  He  quotes  Dr.  Billings  and  Sir  Douglas 
Galton  as  being  in  favour  of  his  views.  It  may,  how- 
ever, be  observed  that  since  Dr.  Billings  wrote  the 
article  quoted  by  Dr  Brown,  he  has  modified  his  view 
on  this  question.  In  the  able  report  written  by  him  for 
the  Trustees  of  John  Hopkin's  Hospital,  Dr.  Billings 
states :  "  But  the  statement  that  this  temporary 
character  should  be  adopted  for  all  hospitals,  and 
especially  all  parts  of  hospitals,  was,  I  am  now  satisfied, 
too  sweeping.  That  is  to  say,  I  do  not  think  it 
necessary  that  all  the  buildings  of  a  hospital  should 
be  destroyed  or  removed  at  certain  regular  intervals, 
in  order  to  prevent  infection,  and  there  are  some  things 
to  be  taken  into  account  in  favour  of  more  permanent 
structures  under  certain  circumstances,  to  which  I  did 

^  Buck's  Hygiene  and  Public  Health,  vol.  ii.  p.  745. 


WARDS 


119 


not  give  sufficient  consideration."  He,  however,  con- 
tinues :  "  Barrack  hospitals  are  best  suited  for  Govern- 
ment purposes,  for  contagious  and  infectious  diseases, 
and  in  general  where  much  subdivision  of  patients 
is  unnecessary,  where  number  of  attendants  and  cost 
of  fuel  is  not  taken  into  account,  and,  as  I  have  above 
remarked,  for  hospitals  which  are  liable  to  be  mis- 
managed."^ Here,  again,  Dr.  Billings  had  clearly  in 
view  the  use  of  wooden  or  barrack  hospitals  for  an 
epidemic  of  one  disease  breaking  out  among  soldiers, 
as  it  is  only  under  such  conditions  that  much  sub- 
division of  patients  would  not  be  necessary.  As 
already  stated,  the  requirements  of  Isolation  Hospitals 
for  small  towns  and  rural  districts,  such  as  those  under 
consideration,  are  about  the  very  opposite  to  what  Dr. 
Billings  had  in  view.  "Subdivision  of  patients"  is 
absolutely  necessary  for  the  separation  of  the  sexes  as 
well  as  for  the  different  diseases.  The  "number  of 
attendants  and  cost  of  fuel "  forms  a  very  important 
item  in  the  expense,  and  a  serious  consideration  in  the 
management  of  such  hospitals,  and  instead  of  being 
"  liable  to  be  mismanaged,"  in  what  I  conceive  to  be 
Dr.  Billings'  use  of  the  term,  no  other  kind  of  hospital 
requires  the  same  assiduous  attention,  for  not  only  are 
the  patients  admitted  with  a  view  to  receive  the  best 
treatment  and  to  be  put  under  the  most  favourable 
conditions  for  recovery,  but  the  greatest  care  is  neces- 
sary to  prevent  the  diseases  from  spreading  from  patient 
to  patient  and  from  them  to  the  attendants  and  others. 

1  Hospital  Cottsfrucfion  mid  Management  (John  Hopkins),  pp.  16  and  17, 


I20  PREVENTION  OF  EPIDEMICS 

The  quotation  from  Sir  Douglas  Galton^  is  as 
follows,  "  I  would  add  one  more  caution.  Do  not 
build  for  a  long  futurity.  Buildings  used  for  the 
reception  of  the  sick  become  permeated  with  organic 
impurities,  and  it  is  a  real  sanitary  advantage,  that 
they  should  be  pulled  down  and  entirely  built  on  a 
fresh  site  periodically." 

Surgeon-General  Billings  and  Dr.  Brown  appear  to 
think  it  necessary  that  such  buildings  should  not  be 
used  for  longer  than  fifteen  years,  and  Dr.  Billings 
states  that  he  -had  seen  a  decided  tendency  to 
erysipelas  and  pyaemia  in  a  characteristic  barrack 
ward,  within  six  weeks  after  it  was  first  occupied. 

The  history  of  the  hospital  ship  Dreadnottght  and  its 
successor  is  of  some  interest  as  bearing  on  this 
question.  In  1858,  Sir  John  Simon  states,  "The  old 
hospital  ship  Dreadnought  has  acquired  a  very  evil 
reputation  for  the  prevalence  of  these  infections, 
dependent,  no  doubt  in  part,  on  the  natural  ill- 
adaptedness  of  a  ship  to  the  purposes  of  a  hospital, 
but  probably  also,  in  part,  dependent  on  organic 
contamination  still  lingering  in  the  wooden  walls 
of  the  wards.  Early  last  year  another  commodious 
ship  was  substituted  for  the  Dreadnotcgkt,  and  Mr. 
Tudor,  the  resident  surgeon,  informs  me  that  whereas 
in  the  two  years  preceding  that  change  nine  out  of 
twenty-two  amputations  had  terminated  fatally,  only 
one    amputation    had    proved    fatal    out    of    sixteen 

1  Construction  of  Hospitals,  Sir  Douglas  Galton,  being  an  address  delivered 
before  the  British  Medical  Association  at  Leeds,  1869. 


WARDS  121 

performed  in  the  year  following  the  change,  and  that 
whereas  formerly  erysipelas  and  hospital  gangrene 
were  so  common  and  so  spreading  as  to  have  let  him 
see  there  at  one  time  as  many  as  eighteen  cases  of 
hospital  gangrene,  he  has  now  scarcely  seen  erysipelas 
except  in  patients  admitted  with  it,  from  whom  as  a  rule 
it  no  longer  spreads  to  the  other  inmates  of  the 
wards.  .  .  .  Little  by  little  since  that  time  the  old 
state  of  things  has  returned,  and  now  the  report  made 
by  the  ship  is,  that  traumatic  infections  are  '  ex- 
cessively frequent,'  that  'operations  do  badly,'  that 
pyaemia  is  frequent."  ^  It  thus  appears  that  within  a 
few  years  this  hospital  ship  had  become  infected  with 
the  micro-organisms  of  various  diseases  to  such  an 
extent  as  to  infect  the  inmates,  just  as  the  decided 
tendency  to  erysipelas  and  pyemia  appeared  in  Dr. 
Billings'  barrack  wards  within  six  weeks. 

This  would  lead  one  to  believe  that  the  destruction 
of  such  buildings  would  become  necessary  in  a  much 
shorter  time  than  fifteen  years,  and  if  this  was  done  as 
often  as  necessary,  it  is  doubtful  if  these  buildings  could 
be  recommended  on  the  "score  of  expense."  If 
instead  of  surgical  cases  being  treated  in  such 
hospitals,  cases  suffering  from  one  infectious  disease 
were  admitted  at  one  time,  and  of  another  infectious 
disease  at  another  time,  the  probability  is,  that  the 
walls  would  soon  become  so  infected  by  the  organisms 
of  the  various  diseases  as  to  defy  disinfection,  and  that 
patients  isolated  for  one  disease  would  frequently  fall 

^  Report  of  Medical  Officer  to  Local  Government  Board,  1863,  p.  64. 


PREVENTION  OF  EPIDEMICS 


victims  to  other  diseases  contracted  in  the  wards.  If 
special  wards  were  always  used  for  each  special 
disease  this  would  not  occur,  although  the  effect  of 
other  evil  influences  might  be  felt. 

To  provide  special  wards  ^  for  every  infectious 
disease  in  thinly  populated  rural  districts  or  small 
towns  would  be  impracticable,  as  I  have  already 
endeavoured  to  show.  If,  however,  the  inner  lining 
of  a  wooden  hospital  ward  consisted  of  some  im- 
permeable material  which  could  in  no  way  harbour 
organic  or  infectious  germs,  as  recommended  by  Dr. 
Brown,^  such  buildings  might  be  made  safe  for  the 
reception  of  cases  of  different  infectious  diseases. 
Under  such  circumstances,  I  do  not  see  the  advantage 
of  a  wooden  outside  wall,  over  stone  or  brick.  In  our 
climate  more  particularly  such  would  require  careful 
and  frequent  painting,  and  the  expense  of  up-keep,  if 
added  to  the  interest  of  the  primary  outlay,  would 
probably  in  time  come  to  equal  that  of  the  more 
expensive  stone  or  brick  building. 

Corrugated  iron  has  been  recommended  by  various 
firms,  as  being  more  durable  than  wood,  and  some 
hospitals  have  been  erected,  both  in  England  and 
Scotland,  of  this  material.  As  hitherto  constructed 
in  England,  neither  corrugated  iron  nor  wooden  hos- 
pitals appear  to  have  given  satisfaction.      Dr.  Thorne 

1  The  wards  of  the  N.W.  Hospital  of  the  Metropolitian  Asylums  Board 
consist  entirely  of  wood,  or  corrugated  iron  and  wood.  Scarlet  fever,  typhoid 
fever,  and  diphtheria  are  treated  there;  1692  cases  in  1892.  Dr.  Gayton,  the 
Medical  Superintendent,  however,  informs  me  that  the  same  wards  are  always 
used  for  the  same  diseases. 

2  Buck's  Hygiene^  vol.  ii.  p.  747. 


WARDS  123 

Thorne  states,  after  a  careful  examination  of  such 
hospitals,  "that,  having  reference,  however,  to  the 
experience  that  has  been  acquired,  I  cannot  but 
conclude  that,  as  regards  permanent  hospitals  in  this 
climate,  wooden  or  iron  buildings  as  ordinarly  con- 
structed are  not  as  a  rule  well  adapted  to  the  purposes 
of  wards.  That  they  can  be  constructed  so  as  to 
ensure  a  reasonable  and  a  fairly  equable  ward 
temperature,  I  do  not  doubt ;  but  when  so  constructed, 
their  original  cost  would  probably  not  fall  short  of,  if 
it  did  not  exceed,  that  incurred  in  the  erection  of 
ordinary  brick  buildings ;  they  would  be  less  durable 
than  these,  and  the  cost  of  maintaining  them  in  a 
proper  state  of  repair  is  undoubtedly  greater  than  that 
needed  for  the  maintenance  of  the  more  substantial 
structure."  ^ 

A  firm  in  Scotland  has  recently  patented  an  improved 
system  of  constructing  weatherboard  and  iron  hospitals. 
Two  layers  of  highly  non-conducting  material  are 
placed  in  the  wall,  "  converting  the  space  between  the 
exterior  and  interior  coverings  into  two  air  compart- 
ments, which  air  compartments  are  insulators  of  them- 
selves." It  is  stated  that  in  this  manner  an  equable 
temperature  can  be  easily  maintained  in  such  buildings 
at  all  seasons.  The  Scottish  Board  of  Supervision 
sanctioned  loans  to  local  authorities  for  the  erection  of 
iron  or  weatherboard  hospitals  on  this  patent.  Port- 
able hospitals  of  corrugated  iron  are  also  constructed 

1  Supplement  to   Report   of  Medical    Officer  to   Local   Government   Board, 
1880  to  18S1,  p.  10. 


124  PREVENTION  OF  EPIDEMICS 

by  the  same  firm.  I  am  not  myself  satisfied  that  an 
equable  ward  temperature  could  be  maintained  in  these 
temporary  movable  buildings.  I  saw  one  of  the  per- 
manent hospitals,  but  before  patients  were  admitted  to 
it.  It  looked  very  well,  though  I  felt  doubtful  as  to 
the  advisability  of  providing  an  inner  lining  of  wood, 
V  grooved,  at  the  junction  of  the  boards.  The  object 
of  the  V  groove  is  to  conceal  the  gaping  which  is 
caused  by  contraction  of  the  wood,  a  very  undesirable 
thing  in  an  infectious  ward.  If  such  hospitals  are  to 
be  internally  lined  with  wood,  a  plain  surface  would  be 
preferable.  The  least  crack  would  be  at  once  noticed. 
The  monotony  of  the  wall  might  be  relieved  by  means 
of  dadoes  and  panelling.  The  fissures  between  the 
deals  should  be  filled  with  cement,  putty,  or  strips  of 
wood  to  prevent  infected  dust  from  being  carried  by 
currents  of  air  into  the  wall.  There  are  various  ways 
in  which  a  wooden  floor  or  wall  might  be  dressed  and 
finished.  If  thoroughly  rubbed  with  glass  or  sand- 
paper, and  brushed  over  with  shellac  dissolved  in 
spirits  of  wine,  and  this  repeated  several  times,  the 
wood  would  get  hardened,  and  might  in  the  case  of 
floors  be  kept  easily  polished  by  being  rubbed  occa- 
sionally with  a  mixture  of  bees-wax  and  turpentine 
(one  pint  to  a  quarter  pound  ^),  or  it  might  be  made 
impermeable,  antiseptic,  and  easily  washed  by  the 
application  of  coal  tar,  mixed  with  heavy  coal  oil,  in 
the  proportion  of  one-fourth  of  coal  oil  to  three-fourths 
of  coal  tar,  by  weight,  not  by  measure.      Before  apply- 

^  Dr.  Howse's  Treatise  on  Hygiene  and  Public  Health,  p.  781. 


WARDS  125 

ing  this  mixture,  the  floor  or  wall  should  be  well 
scrubbed  with  a  hard  fibre  or  metal  brush,  then  washed 
with  soda,  and  finally  impregnated  with  a  solution  of 
one  in  one  thousand  of  corrosive  sublimate.  When  dry, 
a  first  coating  of  the  coal  tar  mixed  with  coal  oil  should 
be  applied  by  means  of  a  painter's  brush,  and  spread 
as  thin  as  possible  with  a  hard  brush.  In  forty-eight 
hours  another  coat  should  be  applied,  and  in  another 
forty-eight  hours  a  third  and  last  coat.  To  keep  the 
floor  in  good  order,  it  is  enough  to  sweep  it  and  to 
wipe  it  now  and  again  with  a  floor  cloth,  wrung  out  in 
water  or  antiseptic  solution,  and  when  dry  to  rub  it  up 
with  a  hair  or  wool  brush,  on  which  some  drops  of 
petroleum  have  been  sprinkled.  The  smell  of  the  coal 
tar  disappears  in  about  three  days.^ 

If  stone  or  brick  is  used  for  the  wall  of  a  ward 
block,  the  wall  should  be  hollow,  so  as  to  prevent 
dampness.  The  inner  face  of  the  wall  should  be 
covered  with  some  material  which  would  present  an 
impervious  polished  surface,  incapable  of  absorbing 
organic  matter,  or  of  aflbrding  shelter  to  the  micro- 
organisms of  disease.  Wall  plaster,  wood,  paint,  var- 
nish, and  wall  paper  absorb  organic  impurities,  as  I 
have  already  shown. 

Sir  Douglas  Galton  ^  states  that  enamelling  the 
walls  like  panels  of  carriages  would  probably  make 
them  impervious,  but  that  it  is  rather  expensive  and 
liable  to  be  scratched  and  damaged.      Most  authorities 

1  Sanitary  Record,  November  15,  1892. 

2  Construction  of  Hospitals,  an  address  delivered  before  the  British   Medical 
Association  at  Leeds  in  1869. 


126  PREVENTION  OF  EPIDEMICS 


appear  to  be  In  favour  of  glazed  brick  or  Parian 
cement.  These  require  to  be  applied  direct  to  stone 
or  brick  walls,  without  any  intermediate  lathing ;  hence 
the  necessity  of  building  the  wall  hollow.  Parian 
cement  is  rather  costly,  and  its  want  of  elasticity  is 
unfavourable  to  its  use  in  ceilings.^  It  is  liable  to 
crack,  and  the  colour  is  not  uniform.^ 

Prof  Jones  ^  states  that  coloured  tiles  or  large 
porcelain  or  glazed  earthenware  slabs,  joined  perfectly 
by  means  of  good  cement,  might  be  used.  A  writer  in 
the  Philadelphia  Medical  Times,  quoted  by  Dr.  Brown 
in  his  article  on  "  Hospital  Construction  and  Manage- 
ment "  in  Buck's  Hygiene,  states  that  glass  would  seem 
to  meet  the  requirements,  being  incapable  of  absorbing 
organic  matter,  not  expensive,  strong  when  sufficiently 
thick,  impervious  to  water  or  dampness,  and  could  be 
made  of  suitable  colours."^  Miss  Florence  Nightingale 
thinks  that  the  best  material  for  woodwork  in  wards  is 
polished  or  varnished  wainscot  oak.  This  would  also 
probably  be  considered  too  expensive.  Mr.  Percival 
Gordon  Smith  ^  states  that  glazed  bricks  have  been 
used  with  good  effect  if  set  with  fine  joints  in  white 
lead  ;  and  Dr.  Thorne  Thorne  "^  is  of  opinion  that  the 
internal  surface  of  walls  is  best  made  of  orlazed  bricks 

o 

1  Sir  Douglas  Gallon.  ^  Miss  Florence  Nightingale. 

■*  Hospital  Constriictioti  and  Management  (John  Hopkins),  p.   112. 

*  Dr.  Snellen  of  Utrecht  informs  me  that  the  inside  of  the  walls  of  the 
operating  room  in  the  Rotterdam  Hospital  is  covered  from  floor  to  ceiling  with 
large  plates  of  glass. 

^  "  On  the  Planning  and  Construction  of  Hospitals  for  Infectious  Diseases," 
Epidemiological  Society  Transactions,  vol.  ii.  1882-83,  p.  142. 

^  Supplement  to  Report  of  Medical  Officer,  Local  Government  Board, 
1880-81,  pp.  12,  13. 


WARDS  127 

or  cement ;  that  the  glazed  brick  walls,  as  in  the 
Delancey  Hospital,  Cheltenham,  are  attractive  and 
admit  of  easy  cleaning,  and  that  the  Parian  cement,  if 
put  on  so  as  to  present  a  hard,  impervious,  porcelain- 
like surface,  as  at  Weymouth,  is  well  adapted  to  the 
purposes  of  hospital  wards.  In  the  absence  of  Parian 
cement  or  glazed  bricks,  the  safest  arrangement  is 
probably  ordinary  brick,  cement,  or  lime  plaster,  period- 
ically scraped  so  as  to  remove  the  tainted  surface  and 
be  again  lime-whited  or  painted.^  If  the  walls  are 
plastered  with  a  view  to  being  painted,  care  should  be 
taken  that  the  painting  is  not  done  before  the  plaster 
is  perfectly  dry. 

To  secure  an  equable  temperature  in  our  climate, 
the  walls  should  be  at  least  fourteen  inches  thick.  The 
angles  at  the  junction  of  the  ceiling  with  the  walls,  of 
the  walls  with  the  floor,  and  of  the  end  with  the  side 
walls,  should  be  rounded  concave,  so  as  not  to  harbour 
dust  and  to  be  easily  cleaned.  Cornices  and  other 
projections  should  be  avoided. 

So  far  as  I  know,  the  shape  universally  adopted  in 
this  country  for  Isolation  Hospital  wards  has  been 
rectangular.  Prof.  Marshall,  who  first  advocated  the 
advantages  of  circular  wards,  gave  a  description  of 
the  Antwerp  Hospital  in  the  British  Medical  Journal 
for  August  1882.  "A  circular  ward  would  be  uni- 
formly free  to  all  quarters  of  the  compass  except  at 
one  point,  where  an  open  or  partially  open  corridor 
would  connect  it  with   the   other  wards   or  with   the 

^  Sir  Douglas  Gallon  on  Cotistnutioti  of  Hospitals. 


128  PREVENTION  OF  EPIDEMICS 

offices,  SO  that  this  form  must  give  free  frontage,  and 
must  also  permit  of  the  freest  possible  access  of  light 
and  air.  If  it  be  true  that  'the  worst  wards  are  those 
where  least  light  and  air  are  provided,'  and  that  '  a 
closed  court,  with  wards  around,  is  the  worst  arrange- 
ment,' then,  since  a  circular  ward  is  the  inverse  of  this 
last-named  plan,  it  would  follow  that  this  form  is  best 
adapted  to  fulfil  the  desired  conditions  ;  its  uniformly 
rounded  exterior,  receding  from  all  adjacent  buildings, 
would  receive  light,  air,  and  wind  from  every  direc- 
tion. There  is,  moreover,  the  least  possible  interfer- 
ence with  light  and  air  to  other  buildings.  The 
circular  form  also  offers  certain  advantages  with 
regard  to  wall  space,  floor  space,  and  cubic  space 
for  each  patient.  It  is  not  adapted  for  wards  with 
less  than  eight  beds." 

With  regard  to  the  cost  of  construction,  Mr.  Percival 
Gordon  Smith  states,  that  while  the  walls  would  cost 
rather  less  to  erect  than  in  the  case  of  rectangular 
wards,  the  flooring  and  roof  would  be  more  costly. 
The  window  sashes,  glass,  and  doors  would  not  need 
to  be  curved,  and,  on  the  whole,  he  believes  that  the 
difference  of  cost  between  a  circular  block  of  wards 
and  an  ordinary  pavilion  for  a  corresponding  number 
of  beds,  with  equal  space  per  bed,  would  be  but  slightly 
in  favour  of  the  straight  building.  As  to  the  artistic 
possibilities  of  a  hospital  with  wards  on  the  circular 
principle,  Mr.  Smith  expresses  himself  very  decidedly. 
"In  skilled  hands,"  he  says,  "it  would  lend  itself  in 
the  most  happy  manner  to  the  production  of  buildings 


WARDS  129 

which  would,  undoubtedly,  be  the  pride  of  the  towns 
possessing  them."  The  freest  exposure  to  light  and 
air,  the  largest  amount  of  floor,  wall,  and  cubic  space, 
are  even  more  necessary  for  infectious  than  general 
diseases.  Circular  wards,  therefore,  appear  to  answer 
the  requirements  of  an  infectious  hospital,  as  well 
as  rectangular  wards  of  moderate  size.  Appended 
is  a  plan  of  a  circular  ward  for  the  isolation  of  small- 
pox, as  suggested  by  Dr.  Burdon  Sanderson  to  the 
Infectious  Hospital  Commission. 

The  difference  in  the  cost  of  circular  and  rectangular 
wards,  according  to  Mr.  Percival  Gordon  Smith  ^  may 
be  safely  said  not  to  exceed  about  2  per  cent. 

Dr.  Louis  Parkes  draws  attention  to  the  fact  that 
if  a  circular  ward  is  to  accommodate  the  same  number 
of  patients  as  an  oblong  ward,  having  an  equal  floor 
measurement  and  cubic  contents,  the  beds  of  the 
patients,  which  are  placed  around  the  wall,  must  be 
very  closely  packed  together,  and  that  8  feet  of  wall 
space  per  bed  cannot,  by  any  possibility,  be  attained.^ 

In  large  hospitals,  whether  for  infectious  or  non- 
infectious diseases,  the  size  of  the  wards  is  governed, 
to  a  large  extent,  by  the  number  of  patients  that  can 
be  attended  to  by  one  nurse.  In  small  hospitals, 
however,  the  size  of  the  wards  should  depend  more  on 
the  classification  of  patients,  according  to  sex  and 
disease,  and  in  some  hospitals  including  arrangements 
for  the  reception  of  private  or  paying  patients. 

1  Article   on    "Dwellings"    in     Treatise    on    Hygiene    and    Public    Health 
(Stevenson  and  Murphy),  vol.  i.  p.  729- 

2  Hygiene  and  Public  Health,  Louis  Parkes,  p.  429. 

K 


PREVENTION  OF  EPIDEMICS 


All  authorities  appear  to  be  agreed  as  to  the 
necessity  in  isolation  wards  of  allowing  2000  cubic  feet 
of  air  space  per  patient ;  1 44  square  feet  of  floor  space  ^ 
and  12  feet  of  wall  space  to  each  bed.  Mr.  Percival 
Gordon  Smith  states  that  it  might  be  better,  if 
intended  for  a  row  of  beds  on  each  side,  to  have 
the  wards  26  feet  wide,  and  13  feet  high,  than  to 
be  24  feet  wide  and  14  feet  high.^ 

The  best  material  for  flooring  ^  is  hard  wood,  such 
as  oak,  hard  pine,  red  deal,  or  ash  well  seasoned. 
Cement  or  tiles  are  not  suited  for  cold  climates. 
All  joints  in  the  floor,  as  well  as  in  the  other  wood- 
work in  the  wards,  should  be  tongued  and  grooved, 
and  put  together  with  white  lead.  It  should  be 
saturated  with  oil  and  resin,  or  treated  as  previously- 
described.  Miss  Florence  Nightingale^  says  that 
well  seasoned  oak  is  the  best,  treated  with  bees-wax 
and  turpentine.  Francis  Brown  ^  states  that  the  floor 
may  be  oiled,  or  treated  with  paraffin,  melted  and 
poured  on  it,  and  then  ironed  in  with  hot  irons. 
Paraffin  dissolved  in  turpentine  may  also  be  applied 
as  a  paint  to  the  walls  and  furniture.^ 


1  Dr.  Thome  Thorne  states  that  the  beds  should  be  so  arranged  as  to  ensure 
for  each  patient  a  floor  space  of  156  square  feet.  Paper  read  in  Architectural 
Section,  Seventh  International  Congress  of  Hygiene  and  Demography,  1891. 

2  Epidemiological  Society  Tra7isactio7is,  vol.  ii.   1882-83,  p.   142. 

3  See  Hospital  Construction  and  Management  (John  Hoplvins)  ;  Norton 
Folsom,  p.  67  ;  Billings,  p.  29 ;  Caspar  Morris,  p.  200 ;  Stephen  Smith, 
p.  301. 

*  Notes  on  Hospitals,  Florence  Nightingale,  pp.  69-71. 
^  Buck's  Hygiene,  vol.  ii.,  Francis  Brown,  p.  748. 

*  "Planning  and  Construction  of  Hospitals,"  Epidemiological  Society  Trans- 
actions, P.  G.  Smith,  1882,  vol.  ii.  p.  142.      Galton,  Co]istniction  of  Hospitals. 


WARDS 


131 


Opposite  windows  should,  if  possible,  be  provided 
on  both  sides  of  the  ward.  They  should  extend  from 
2  feet  6  inches  or  3  feet  of  the  floor,  to  within  i  foot 
of  the  ceiling.  It  is  desirable,  if  possible,  to  have 
a  window  between  each  bed.  Sir  Douglas  Galton  ^ 
is  of  opinion  that  "one  superficial  foot  of  window 
space  to  from  50-55  cubic  feet  of  space  [in  the  ward], 
will  afford  a  light  and  cheerful  room  ;  but  that  this 
depends  much  on  the  situation,  and  upon  the  walls 
being  very  light  colours."  One  square  foot  of  window 
opening  to  about  70  cubic  feet  is  more  advantageous 
according  to  Dr.  Thorne  Thorne.  Too  much  window 
space  makes  it  difficult  to  regulate  the  temperature 
of  wards  during  the  heat  of  summer  or  cold  of  winter. 
Dr.  Angus  Smith,  F.R.S.,"  made  careful  experiments 
regarding  this  question  in  the  Children's  Hospital  at 
Pendlebury,  Manchester.  In  this  hospital  the  window 
space  is  i  square  foot  for  every  35  cubic  feet  space. 
Dr.  Smith  found  that,  with  such  a  large  window  space, 
it  was  not  possible  to  keep  the  ward  air  pure,  and  at 
the  same  time  equably  warm. 

All  windows  should  be  double  sashed,  and  made 
to  open  from  the  top  and  bottom.  It  might  be 
desirable  to  use  plate  glass  in  the  windows,  so  as  to 
economise  heat.^  Every  window  in  a  hospital  ward 
should,  in  addition  to  being  double  sashed,  have  a  part 

1-   ConsU-uction  of  Hospitals,  p.  27. 

2  Public  Health,  Wynter  Blythe,  p.  559. 

3  Sir  Douglas  Galton,  Construction  of  Hospitals.  Dr.  Russell,  Medical 
Officer  of  Health  for  the  City  of  Glasgow,  informs  me  that  the  windows  of  the 
Belvidere  Hospital  are  double  glazed,  which  is  found  necessary  and  sufficient 
for  the  maintenance  of  heat. 


PREVENTION   OF  EPIDEMICS 


above  the  upper  sash,  hinged  below,  provided  with 
side  flaps  and  made  to  open  inwards.  This,  while 
providing  ventilation,  prevents  down  draught. 

Ventilation  and  warming  of  the  ward  may  well 
be  considered  together,  as,  in  this  country,  the 
most  powerful  aids  to  ventilation  are  open  fireplaces 
and  ventilating  stoves,  by  means  of  which  both 
purposes  are  carried  out.  In  a  variable  climate,  such 
as  that  prevailing  in  this  country,  with  a  high  summer 
and  low  winter  temperature,  often  accompanied  respec- 
tively by  calm  weather  or  high  winds,  the  heating 
and  ventilation  of  wards,  so  as  to  secure  the  desired 
temperature  and  purity  of  air,  are  not  so  easily 
attained  as  might  at  first  sight  appear.  The  opinion 
of  Miss  Florence  Nightingale,  a  lady  of  uncommon 
experience  in  hospital  management,  is  of  value  as 
bearing  on  this  question.  Miss  Nightingale  writes 
that  "  Nature  affords  air  to  both  sick  and  healthy,  of 
varying  temperature  at  different  hours  of  the  day 
and  night  and  season  ;  always  apportioning  the 
quantity  of  moisture  to  the  temperature,  and  pro- 
viding continuous  and  free  movement  (of  the  air) 
everywhere.  We  all  know  how  necessary  the  varia- 
tions of  weather,  temperature,  and  season  are  for 
maintaining  health  in  healthy  people.  Have  we  any 
right  to  assume  that  the  natural  law  is  different  in 
sickness  ?  In  looking  solely  at  combined  warming 
and  ventilation,  to  secure  to  the  sick  a  certain  amount 
of  air  at  60°  Fahr.,  paid  for  by  contract,  are  we  acting 
in  accordance  with  physiological  law  }     Is  it  a  likely 


VENTILATION  AND    WARMING  133 

way  to  enable  the  constitution  to  rally  under  serious 
disease,  to  under-cook  all  the  patients  day  and  night, 
during  all  the  time  they  are  in  hospital,  at  one  fixed 
temperature  ?  I  believe  not !  On  the  contrary,  I 
am  strongly  of  opinion, —  I  would  go  further  and  say 
— I  am  certain  that  the  atmospheric  hygiene  of  the 
sick-room  ought  not  to  be  very  different  from  the 
atmospheric  hygiene  of  a  healthy  house."  ^  ...  "In 
the  wooden  hospitals  before  Sebastopol,  with  their 
pervious  walls  and  open -ridge  ventilation,  in  which 
the  patients  sometime  said  that  they  would  get  less 
snow  if  they  were  outside,  such  a  thing  as  catching 
cold  was  never  heard  of.  The  patients  were  well 
covered  with  blankets,  and  were  all  the  better  of  the 
cold."^  "Patients  in  bed  are  not  peculiarly  liable  to 
catch  cold,  and  in  England,  where  fuel  is  cheap, 
somebody  is  indeed  to  blame  if  the  ward  cannot  be 
kept  warm  enough,  and  if  the  patients  cannot  have 
bedclothing  enough,  for  as  much  fresh  air  to  be 
admitted  from  without  as  suffices  to  keep  the  ward 
fresh.  No  artificial  ventilation  will  do  this.  Except 
in  a  few  cases  well-known  to  physicians,  the  danger 
of  admitting  fresh  air  directly  is  very  much  exagger- 
ated." 

Agreeing  in  the  main  with  all  this,  it  must  be 
understood  that  every  care  should  be  taken  to  provide 
means  for  heating  and  ventilating  wards,  so  as  to 
have  the  temperature  more  or  less  under  control. 
Cases  are  now  and  then  met  with  in  every  hospital 

1  Notes  on  Hospitals,  pp.  75  and  'jQ.  2  /^/^_  p_  j^_ 


134  PREVENTION  OF  EPIDEMICS 

ward  which  require  special  treatment,  and  it  may  be 
desirable,  for  the  sake  of  such  patients,  to  keep  the 
temperature  higher  for  a  time  than  is  necessary  for 
the  other  inmates.^  Unless  provision  is  made  for 
efficient  ventilation  and  warming  under  such  circum- 
stances, the  benefit  that  would  accrue  from  the  higher 
temperature  might  be  lost  by  the  increased  impurity 
of  the  air.  Still,  to  attain  this  it  does  not  appear  to 
be  necessary  to  provide  any  elaborate  means  of  arti- 
ficial ventilation  or  heating  for  small  hospitals  in  this 
country.  The  condition  to  be  secured  is  such 
temperature  of  the  air  as  may  be  required  at  different 
times,  to  suit  the  conditions  of  the  patients  under 
treatment.  Slight  variations  in  the  temperature  are 
no  doubt  rather  beneficial  than  otherwise,  and  a  cooler 
temperature  at  night,  more  particularly  in  the  tropics, 
acts  as  a  tonic.  Any  one  who  has  visited  tropical 
countries  cannot  but  be  impressed  with  this  fact.  Yet 
the  conditions  in  the  tropics  are  different.  There, 
at  night,  there  is  a  change  from  extreme  heat  during 
the  day  to  a  refreshing  moderate  coolness  at  night, 
but  in  this  climate  the  change  may  be  from  a 
moderate  heat  or  cold  during  the  day  to  an  extremely 
low    temperature  at  night.      In  regard   to    the  purity 


1  Prof.  Jones  of  the  University  of  Louisiana,  and  formerly  surgeon  of  the 
Confederate  forces,  states,  "  In  convalescents  with  fever  and  other  acute  diseases, 
the  forces  having  been  reduced  by  the  active  chemical  changes  and  rapid  meta- 
morphosis of  the  blood  and  tissues  and  organs,  sudden  changes  of  temperature, 
and  especially  cold,  act  injuriously.  The  rule,  therefore,  established  in  both 
civil  and  military  hospitals,  that  convalescents  from  fever  and  acute  diseases  must 
be  kept  warm,  should  be  rigidly  enforced." — Hospital  Construction  and  Manage- 
ment (John  Hoplcins). 


VENTILATION  AND    WARMING  135 

of  the  air,  the  object  to  be  aimed  at  is,  that,  in  the 
wards,  it  will  never  fall  rhuch  below  the  standard  of 
the  external  air.  It  should  not  contain  more  than 
0.5  per  1000  volumes  of  carbonic  acid  gas,  nor  such 
an  amount  of  organic  matter  as  to  be  perceptible  to 
the  sense  of  smell.  The  breathing  of  vitiated  air  will 
thus  be  prevented,  and  the  risk  of  infection  spreading 
from  the  patients  to  the  attendants,  or  from  the 
occupants  of  one  ward  to  those  of  another,  will  be 
reduced  to  the  minimum,  while,  at  the  same  time, 
the  walls,  floors,  and  furniture  are  less  likely  to  absorb 
or  retain  infectious  agents.  When  a  proper  volume  of 
fresh  air  is  continually  being  mixed  with  that  in  a 
ward,  and  a  continuous  current  is  ever  bearing 
away  every  volatile  taint  and  infectious  particle,  the 
atmosphere  is  always  prevented  from  becoming 
charged  with  the  organisms  of  disease.  A  person 
entering,  or  being  treated  In,  a  well-ventilated  ward, 
in  contradistinction  to  a  ward  in  which  the  air  is 
charged  with  the  emanations  from  the  sick,  may  be 
compared  to  a  person  standing  "on  a  plain  across 
which  a  file  of  men  are  firing.  The  chances  of  escape 
are  of  course  better  If  there  are  but  ten  men  firing 
instead  of  a  hundred." 

A  healthy  adult  person  requires  3000  cubic  feet 
of  fresh  air  per  hour.  In  order  that  the  respiratory 
Impurities  may  not  exceed  0.2  per  1000,  or  a  total 
impurity  of  0.6  per  1000.  If  the  cubic  space  per  head 
be  1000  feet,  then  the  air  needs  to  be  changed  three 
times  every  hour.      If  the  renewal  Is  affected  steadily 


136  PREVENTION  OF  EPIDEMICS 

and  gradually,  the  cold  air  is  broken  up  and,  mixing 
with  the  warm  air  of  the  apartment,  creates  no  draught.^ 
Dr.  de  Chaumont  found  that  the  smell  of  organic 
matter  was  perceptible  in  hospitals  when  the  carbonic 
acid  amounted  to  0.166  per  1000,  so  that  if  3000  cubic 
feet  be  required  per  hour  in  health,  4000,  or  a  third 
more,  should  be  allowed  in  sickness  of  an  ordinary- 
character,  and  6000  in  infectious  hospitals  appears  to 
be  necessary.^  To  supply  this  amount  without  caus- 
ing draught,  the  cubic  space  must  be  proportionately 
increased.  Two  thousand  cubic  feet  is  recommended 
by  almost  all  authorities  for  infectious  wards.  To 
secure  that  this  amount  of  air  per  patient  per  hour  is 
diffused  equally  at  appropriate  temperatures  through 
a  hospital  ward,  various  appliances  have  been  used. 
Mr.  Percival  Gordon  Smith  ^  states  that  he  knows 
instances  where  it  was  not  possible  to  maintain  a 
temperature,  in  enteric  or  typhoid  fever  wards,  of  42° 
Fahr.,  and  this  with  the  windows  practically  closed. 
He  is  strongly  of  opinion,  and  he  is  supported  by 
other  authorities,  that  for  small  hospitals  in  our  climate, 
powerful  stoves  or  grates  are  best,  and  that  these  if 
necessary  may  be  supplemented  with  hot-water  pipes. 
It  is  not,  however,  sufficient  to  trust  to  windows  and 
fireplaces  only  for  ventilation.  Sheringham  ventilators, 
with  direct  openings  through  the  wall,  should  be  provided 
between  the  windows,  close  to  the  ceiling,  for  the  admis- 

1  Hygiene  and  Ptiblic  Health,  Louis  Parkes,  pp.  224  and  226. 

2  Dr.  De  Chaumont,  "Theory  of  Ventilation,"  in  Proceedings  of  the  Royal 
Society,  and  Hygiene  and  Public  Health,  p.  1 46. 

3  Epidemiological  Society  Transactions,  1882-83,  vol.  ii. 


VENTILATION  AND    WARMING  137 

sion  of  fresh  air.  Galton  states  that  the  combined  area 
of  these  should  be  at  least  one  square  inch  for  every 
100  cubic  ft.  of  space.  Outlet  shafts  should  also  be 
provided,  such  as  Boyle's  or  Buchan's  roof  extracting 
ventilators.  These  should  be  connected  with  the 
wards  by  enclosed  vertical  shafts.  A  shaft  should 
also  be  made  in  the  wall  alongside  the  chimney, 
dividing  at  a  certain  height  into  two,  with  an  opening 
some  feet  from  the  ceiling  near  the  corners  of  the 
ward.  The  heat  of  the  chimney  will  cause  a  draught, 
which  will  extract  foul  air  from  the  angles  of  a  ward, 
where  it  would  be  likely  to  remain  more  or  less  stag- 
nant. Horizontal  trunks  are  objectionable,  as  likely 
to  become  receptacles  for  infected  dust.  Mr.  Percival 
Gordon  Smith  also  recommends  short  flues,  passing 
directly  through  the  wall,  at  the  level  of  the  floor,  one 
beneath  at  the  head  of  each  bed,  and  states  that  such 
openings  may  have  a  superficial  area  of  100  square 
inches  or  more ;  and  that  if  provided  with  sliding 
shutters,  for  occasionally  closing  them,  they  are  not 
in  practice  found  to  be  inconvenient.  Sir  Douglas 
Galton  found  that  an  adequate  change  of  air  will  not 
be  satisfactorily  obtained  in  all  cases,  unless  the  outlet 
or  extracting  shafts  have  a  sectional  area  of  at  least 
I  inch  to  every  50  cubic  feet  of  space  in  the  room, 
for  the  upper  floors  ;  of  1  inch  to  every  55  cubic  feet 
in  the  rooms  on  the  floors  below  ;  and  of  i  inch  to  every 
60  cubic  feet  for  rooms  on  the  lower  floors,  but  that  this 
depends  to  some  extent  on  the  height  of  the  rooms. ^ 

^   Consti-uction  of  Hospitals,  p.   15. 


138  PREVENTION  OF  EPIDEMICS 

All  openings  for  the  admission  of  air  should  be 
made  so  as  to  allow  of  being  easily  cleaned,  and 
this  should  be  done  every  time  the  ward  is  disinfected. 
It  would  also  be  desirable  that  the  extracting  shafts 
should  be  capable  of  being  cleaned  and  dusted.  These 
also  sometimes  act  as  inlets,  and  they  are  liable  to 
contain  infected  dust.  In  addition,  or  supplementary 
to  open  fireplaces  or  stoves,  it  may  in  some  cases  be 
desirable  to  provide  hot-water  pipes  along  the  side 
walls,  fixed  about  4  inches  above  the  floor.  Such  an 
arrangement  would  permit  of  cleaning  and  dusting. 
At  the  same  time  they  would  be  found  very  desirable 
on  some  occasions  for  warming  the  air  as  it  filters 
through  the  openings  already  mentioned. 

The  nurse's  room  should  be  placed  in  the  most 
convenient  position  for  the  ward  or  wards  which  she 
is  intended  to  supervise.  In  small  hospitals  this  room 
should  be  regarded  as  a  combination  of  a  ward  kitchen 
or  scullery,  and  nurse's  duty-room.  It  should  not  be 
used  as  a  sleeping  apartment.  It  should  be  provided 
with  a  small  range  or  fireplace,  with  an  oven  and 
boiler.  The  oven  would  be  useful  for  keeping  various 
articles  of  food  or  drink  warm.  The  boiler  should 
be  of  sufficient  capacity  to  provide  sufficient  hot 
water  for  bathing  purposes,  as  well  as  for  washing 
and  scrubbing.  It  might  in  some  cases  be  supple- 
mented by  a  hot -water  geyser,  such  as  that  supplied 
by  Doulton  of  Lambeth,  which  would  provide  boiling 
water  in  a  few  minutes  at  any  time  of  the  day  or 
night,    should   the  fire   be   low  or  out.       The   nurse's 


IVAJ^D  ACCESSORIES  I39 

room  should  also  be  provided  with  locked  cupboards 
for  the  ward  crockery,  for  medicines,  and  other 
articles.  A  cool  larder  of  small  size,  with  wire  gauze 
sides,  might  be  conveniently  placed  outside  the 
window,  opening  inside  by  a  hinged  door  or  pane. 
In  summer  weather  it  should  be  kept  comparatively 
cool  by  being  covered  with  a  few  folds  of  clean  linen 
wrung  out  of  cold  water. 

Inspection  windows  should  be  placed  in  such  posi- 
tions as  will  enable  the  nurse  to  see  into  the  wards 
on  both  sides.  A  scullery  sink  should  also  be  pro- 
vided. 

A  cupboard  or  small  closet  should,  if  possible,  be 
placed  in  a  warm  and  dry  locality,  and  be  of  sufficient 
size  for  the  storage  of  all  the  clean  linen  and  bed- 
clothes required  in  the  ward  block. 

A  separate  bath-room,  with  hot  and  cold  water, 
should  be  provided  for  wards  of  six  beds  and  upwards. 
For  smaller  wards,  a  light  bath  on  noiseless  wheels 
might  be  used  for  two  or  three  rooms.  In  such  cases 
a  convenient  place  for  the  bath  is  in  the  verandah,  as 
may  be  seen  in  the  designs  of  the  Local  Government 
Board,  see  appendix. 

In  all  hospitals,  of  whatever  size,  it  is  very  desir- 
able to  have  an  undressing-room,  a  bath-room,  and  a 
dressing-room  so  placed  as  to  enable  patients  to  leave 
the  hospital  after  taking  their  final  bath,  and  dress- 
ing in  non-infected  clothing,  without  returning  to  the 
wards.  This  might  be  secured  by  having  a  door  from 
the  outside  opening  into  the  lobby  leading  into   the 


I40  PREVENTION  OF  EPIDEMICS 

bath-room.  If  the  bath  is  fixed,  it  should  be  placed 
with  one  end  to  the  middle  of  one  of  the  walls,  and  be 
free  on  both  sides.  The  bath,  as  well  as  the  floor  and 
walls  of  the  bath-room,  should  be  of  such  material  as 
will  not  retain  infection,  and  be  easily  cleansed  and 
disinfected. 

A  slop  sink  with  hot  and  cold  water,  and  a  water 
or  earth  closet,  should  also  be  erected  for  wards  of  six 
beds  and  upwards. 

The  position  of  these,  as  well  as  of  the  bath-room, 
may  be  seen  from  the  plans.  They  should  always, 
however,  be  separated  from  the  wards  by  a  lobby  with 
cross  ventilation.  The  sinks  should  be  fitted  with 
vitrified  stoneware  sink  or  receivers.  In  small  hos- 
pitals in  rural  districts,  earth  closets  are  preferable. 
Instead  of  earth  they  should  be  supplied  with  powdered 
peat  or  sawdust,  and  the  contents  mixed  with  petroleum 
or  paraffin,  and  burnt  daily.  A  small,  simple  destruc- 
tor should  be  erected  in  connection  with  the  outhouses 
for  the  purpose. 

Every  hospital,  of  whatever  size,  should  have  a 
plentiful  supply  of  pure  water  ;  without  this  the  neces- 
sary cleanliness  is  impossible.  One  of  the  first  requi- 
sites in  securing  a  site  for  a  hospital  is  the  water  supply. 
Dr.  Parkes  states  that  from  forty  to  fifty  gallons  per 
head  per  day  are  often  used.  He  gives  the  following 
as  being  near  the  quantity  required  : — 


WATER  SUPPLY  AND  DRAINAGE  141 


For  drinking  and  cooking,  washing  kitchen 

and 

Gallons  daily. 

utensils        .... 

2    to       4 

For  personal  washing  and  general  baths 

18     ,,     20 

For  laundry,  washing 

5   „      6 

Washing  hospital,  utensils,  etc.    . 

3   „      6 

Water-closets      .... 

10 

38  to  46 

According  to  Mr.  Perclval  Gordon  Smith/  "  the 
drainage  of  an  infectious  hospital  differs  in  no  essential 
point  from  the  drainage  of  any  other  building."  He 
states  that  "  it  should  be  clearly  understood  by  the 
contractor,  and  by  all  concerned,  that  the  drains  on 
completion  should  be  tested  in  lengths  by  plugging 
the  lower  end  of  each  length,  and  then  filling  the 
length  of  drain  with  water.  If  the  drain  then  failed 
to  hold  the  full  quantity  of  water  for  a  specific  time — 
say  four  or  six  hours — it  would  be  evident  that  means 
of  leakage  existed,  for  which  the  contractor  would  be 
held  responsible.  The  drains  should  be  laid  in  direct 
lines,  with  uniform  gradients  between  the  several  points, 
where  a  change  of  direction  or  gradient  occurs  ;  and  at 
each  of  these  points  means  of  access  to  the  drains 
should  be  provided,  either  by  a  manhole  or  a  lamphole, 
so  that  the  entire  system  of  drains  could  be  inspected 
with  ease  at  any  moment." 

The  drains  should  nowhere  pass  under  any  part  of 
the  building.  Every  care  should  be  taken  by  means 
of  ventilation  and  trapping  to  prevent  the  return  of 

1  "  On  the  Planning  and  Construction  of  Hospitals  for  Infectious  Diseases," 
Epidemiological  Society  Transactions,  vol.  ii.  1882-83,  P-  ^^57- 


142  PREVENTION  OF  EPIDEMICS 

sewer  gas  into  any  part  of  the  building.  If  within 
easy  distance  of  the  sea,  the  drain  should  be  carried 
below  low-water  mark.  In  rural  districts  far  from  the 
sea,  the  drainage  should  not  be  discharged  into  a  river 
or  a  cesspool.  If  possible,  sufficient  land  should  be 
acquired  to  utilise  the  drainage  by  irrigation  or  sub- 
soil filtration,  for  which  also  ashes  and  other  garbage 
mieht  be  utilised. 

Every  hospital  should  have  a  laundry  and  drying- 
room,  a  mortuary,  a  disinfecting-room  with  a  tank  in 
which  soiled  or  infected  clothes  could  be  immediately 
steeped  in  a  disinfecting  fluid,  an  ashpit,  and  a  destruc- 
tor for  excretions  and  garbage.  In  most  hospitals  an 
ambulance  shed  should  be  provided.  These  outhouses 
should  be  erected  at  least  forty  feet  from  the  ward 
blocks,  and  as  far  from  the  administrative  building  and 
from  the  wall  surrounding  the  hospital  grounds. 

Except  in  very  small  hospitals  the  wash-house  and 
laundry  might  be  in  separate  apartments.  They  should 
be  in  size  and  equipment  proportionate  to  the  size  of 
the  hospital  and  the  disinfectant  requirements  of  the 
district.  The  wash-house  should  have  tiled  or  cemented 
floor,  non-absorbent  walls,  and  be  fitted  with  wash- 
tubs  of  glazed  porcelain  or  fireclay,  as  well  as  with  a 
boiler  and  other  necessary  appliances.  The  laundry 
should  have  a  mangle  and  ironing  table,  and  shelves 
for  clothes.  The  stoves  for  heating  the  irons  should 
be  utilised  at  the  same  time  for  heating  the  drying- 
room.  In  all  places,  when  the  weather  permits,  all 
clothes  should  be  dried  in  the  open  air. 


HOSPITAL  ACCESSORIES  143 

The  mortuary  should  be  of  sufficient  size,  well 
ventilated,  and  lighted  from  the  roof  It  should  have 
a  tiled  or  cemented  floor  and  walls,  so  that  it  can  be 
easily  washed  with  water.  It  should  have  a  slate 
bench  for  coffins,  and  a  table  for  post-mortem  examina- 
tions, as  well  as  a  sink  provided  with  a  water  tap.  It 
is  desirable  to  have  an  inspection  window  through 
which  friends  may  be  able  to  have  a  look  at  the  dead 
without  danger,  and  the  door  should  be  in  such  a 
position  that  the  removal  of  the  dead  cannot  be  seen 
by  patients  in  the  wards. 

The  ashpit  should  be  properly  constructed,  with 
cement  floor  and  walls,  and  roofed,  and  be  of  small 
size.  A  dry  earth  closet  should  be  erected  in  connec- 
tion with  the  outhouses  for  the  use  of  the  staff,  and  in 
hospitals  for  one  infectious  disease  it  may  only  be  used 
by  the  patients,  as  in  Plan  A  of  the  Local  Government 
Board. 

There  is  no  destructor  for  burning  excretions  or 
garbage  suitable  for  small  hospitals,  so  far  as  I  know, 
in  the  market,  but  I  have  no  doubt  the  demand  would 
soon  create  a  supply. 

It  is  necessary  to  devote  a  separate  chapter  to  the 
subject  of  disinfection. 

The  furniture  of  isolation  wards  should  be  selected 
with  a  view  to  the  comfort  of  the  inmates  and  the 
cheerfulness  of  the  wards,  while  at  the  same  time  due 
regard  must  be  paid  to  economy.  The  furniture  should 
be  of  such  material  as  will  be  least  liable  to  harbour 
infection,  or  of  such  a  nature  that  it  can  be  rendered 


144  PREVENTION  OF  EPIDEMICS 

free  of  infection  with  the  greatest  possible  ease.  Some 
articles  which  entail  much  trouble  and  expense  in  dis- 
infecting may  preferably  be  of  cheap  material,  so  that 
no  great  loss  will  be  incurred  if  at  any  time  it  be  found 
necessary  to  destroy  them.  The  wards  should  have 
no  curtains,  carpets,  rugs,  or  mats  of  any  kind. 

The  bedsteads  should  be  of  iron,  painted  or  enam- 
elled, and  should  be  provided  with  wire,  coil,  or 
spring  mattresses.  The  bedsteads  should  be  from 
6  feet  to  6|-  feet  long,  3  feet  broad,  and  about  2  feet 
high.     A  few  cots  should  be  provided  for  children. 

The  difficulty  of  providing  a  suitable  mattress  for 
small  Isolation  Hospitals  is  not  yet  solved. 

Miss  Florence  Nightingale^  states  that  "no  bed- 
ding but  the  hair  mattress  has  yet  been  discovered 
that  is  fit  for  hospitals.  It  does  not  readily  retain 
miasma,  and  if  it  does,  heat  easily  disinfects  it.  It 
may  be  washed.  It  is  not  hard  to  the  patient.  It 
saves  the  objectionable  use  of  a  blanket  under  the 
patient.  There  have  been  repeated  objections  made  to 
horse-hair  on  account  of  the  current  expense  .  .  .  but 
it  is  less  than  is  supposed.  .  .  .  Straw  palliasses  are 
inadmissible — cold,  abstract  heat,  and  lessen  the  chance 
of  recovery."  On  the  other  hand,  Mr,  A.  G.  Howse^ 
states  that  attempts  have  been  made  to  disinfect  a  hair 
mattress  en  masse  by  subjecting  it  to  both  dry  and 
moist  heat  at  a  temperature  of  350°  Fahr.,  but  that  the 
texture  becomes  greatly  damaged  in  the  process,  and 

1  Notes  on  Hospitals,  pp.  80-81. 

2  Treatise  on  Hygiene  and  Public  Health  (Stevenson  and  Murphy),  vol.  i. 
P-  783. 


IVARB  FURNITURE  145 

that  if  a  hair  mattress  is  to  be  disinfected,  it  must  be 
pulled  entirely  to  pieces.  The  expense,  according  to 
Miss  Florence  Nightingale,^  is  not  excessive,  being 
about  2jd.  to  2|-d.  per  bed,  and  the  loss  of  hair  at  i|d. 
or  2d, 

Dr.  Parsons^  states  that  horse  hair  will  bear  a 
higher  temperature  than  woollen,  cotton,  or  linen  goods 
— that  the  process  of  curling  it  for  stuffing  chairs  is 
effected  by  exposing  it  to  a  temperature  of  300°  Fahr. 

Dr.  Thorne  Thorne^  states  that  he  found  thin  horse- 
hair beds  over  spring  coiled  wire  mattresses  in  use 
in  Isolation  Hospitals  in  England,  and  highly  spoken 
of  both  by  the  staff  of  the  hospitals  and  by  the  patients, 
and  that,  owing  to  the  elasticity  of  the  spring  mattress, 
and  consequently  the  horse-hair  beds  being  less  than 
the  usual  thickness,  they  are  easily  dealt  with  in  an 
efficient  disinfecting  stove. 

As  I  have  already  shown,  efficient  disinfecting 
stoves  are,  owing  to  their  expense,  not  easily  provided 
for  small  Isolation  Hospitals  in  this  country.  It 
remains,  therefore,  to  be  considered  what  is  the  best 
substitute  for  a  hair  mattress  in  small  hospitals. 

Flock  or  woollen  mattresses  must  also  be  cleaned 
and  disinfected  by  superheated  steam.  Straw  or  chaff 
or  husk  beds  appear  to  be  the  only  alternatives.  A 
chaff  bed  is  more  comfortable  than  a  straw  bed,  but  it 
is  difficult  to   get   clean   chaff  in    sufficient  quantity. 

1  Notes  071  Hospitals,  p.  80. 

2  Report  on  Disinfection  by  Heat,  1884,  p.  22. 

3  Supplement  to  Report  of  Medical   Officer   of  Local    Government  Board, 
1880,  p.  16. 

L 


146  PREVENTION  OF  EPIDEMICS 

When  these  are  used  the  tick,  when  necessary,  may 
be  emptied  and  disinfected  and  its  contents  burned. 
Such  beds  are  in  use  in  many  Isolation  Hospitals  in 
this  country  at  the  present  time. 

Draw  sheets  and  Mackintoshes  should  be  used  to 
prevent  the  beds  from  getting  soiled,  and  render  the 
necessity  of  destroying  them  less  frequent. 

A  small  square  table  should  be  placed  beside  each 
bed  for  the  convenience  of  the  patient.  These  should 
be  painted  and  varnished  or  enamelled.  Lockers  are 
objectionable.  In  spite  of  all  care  on  the  part  of  the 
nurses  they  soon  become  depositories  of  all  kinds  of 
rubbish,  and  when  the  ward  is  to  be  cleaned  out  for 
another  disease  It  is  extremely  difficult  to  disinfect 
lockers  properly.  There  should  be  one  or  more 
similar  tables,  but  of  larger  size,  for  the  general  use  of 
the  ward. 

A  few  reclining  and  other  chairs  should  be  pro- 
vided for  convalescents.  They  should  have  no  stuffing 
or  cushions.  In  the  case  of  very  weak  or  exhausted 
patients  air  cushions  may  be  used. 

Other  articles  of  furniture  need  no  description. 
Appended  Is  a  list  of  furniture  and  utensils  required 
In  hospital  wards. 

The  administrative  building  should  be  comfortably 
furnished,  more  or  less  like  a  private  dwelling  Intended 
for  persons  of  the  same  social  grade  as  those  likely  to 
occupy  It.  The  equipment  of  the  kitchen  must  of 
course  be  in  excess  of  the  requirements  of  the  number 
of  nurses  and  officers.     It  should  be  sufficiently  large 


JVARD  FURNITURE 


147 


and  equipped  to  cope  with  the  work  required  to  provide 
varied  nourishments  for  the  largest  number  hkely  at 
any  time  to  be  in  the  hospital,  whether  patients  or 
officers. 

A  medicine  chest  or  press  should  be  provided  in 
the  administrative  building,  in  the  medical  officers' 
room  when  such  is  provided,  or  in  the  absence  of  this 
room,  in  the  matron's  or  head  nurse's  sitting-room.  It 
should  contain  such  medicines  as  are  likely  to  be 
required. 

List  of  Furniture  required  for  Isolation  Hospitals,  2 
wards  and  8  patients  (modified  from  Dr.  Norton  Folsom's 
list).i 


8    Bedsteads    (Iron    with    spring 

mattresses) 
10  Hair  mattresses  or 
10  Straw  or  chaff  mattresses 
10  Pillows 
10  Bolsters 
16  Quilts 
32  Sheets 

8  Half  sheets 

4  Mackintoshes 
16  Pillow  cases 
16  Bolster  slips 

4  Air  cushions 
24  Shirts  and  chemises 

4  Table  cloths 

4  Table  covers 
18  Dressing  towels 

4  Roller  towels 

2  Reclining  chairs 

8  Small  wooden  chairs 

2  Wheeled  chairs 

8  Small  tables 

2  Large  tables  for  wards 


•?:  o 


I  Square  table  for  nurse 

1  Rocking  chair       „ 

2  Small  chairs  ,, 

1  Table  cover 
Shirt  buttons 

I  Iron  bedstead,, 
I  Washstand      ,, 
Bedclothes       ,, 
4  Towels  ,, 

4  Screens  for  wards 

2  Baskets  for  soiled  linen 
8  Bedstead  card  frames 

2  Clocks 

2  Thermometers  (Ward) 

8  Flower  vases 

2  Clothes  brushes 

8  Hair  brushes 

8  Combs  (large) 

8  Combs  (small) 

2   Nail  brushes 

1  Pair  scissors 

2  Soap-dishes 
2  Wash-basins 


^  Hospital  Cojistriiction  and  Management  (John  Hopkins),  p.  98. 


148 


PREVENTION  OF  EPIDEMICS 


2  Baths 

4  Bath  sponges 

2  Towel  stands 

2  Slipper  pans 
2  Commodes 
8  Wash  bowls 

2  Looking  glasses 

4   Hot-water  bottles  or  pans 

8   Knives 

8  Spit  cups 
2  Spittoons 
I  Chamber  pail 

8  Forks 

I  Dust  pan 

2  Carving  knives  and  forks 

I  Filler 

I  Soup  ladle 

2  Fenders 

8  Table  spoons 

2  Pokers 

8  Tea  spoons 
1  Corkscrew 

2  Tongs 

2  Coal  scuttles 

8  Plates 

2  Shovels 

8  Small  plates 

2  Small  shovels 

8  Bowls 

4  Candlesticks 

8  Mugs 

2  Medicine  cups 

4  Lamps 
4  Funnels 

2  Measure  glasses 

I  Oil  can 

8  Cups  and  saucers 
I  Sugar  Bowl 

I  Lamp  filler 
4  Shades 

I  Cream  jug 
8  Tumblers 
4  Salt  cellars 

2  Match  safes 

I  Pair  lamp  scissors 

I  Dish  Tub 

I  Meat  dish 

2  Brooms 

I  Soup  tureen 

2  Dust  Brushes 

I  Coffee  pot 

6  Dusters 

I  Tea  pot 

2  Window  brushes 

I  Kettle 
I  Sugar  box 
I  Bread  box] 

2  Mops 

2  Dish  Mops 

2  Scrubbing  brushes 

4  Trays 

2  Glass  or  earthenware  jars 

for 

2  Water  pitchers 

4  Bed  pans  (with  covers) 

[disinfectants 

Allowance  of  Linen  per  Bed  in  chief  General 
Hospitals.     Henry  C.  Burdett/ 


Medical  Wards 
4  Sheets 
3  Blankets 
I  Counterpane 
3  Pillow  cases 


I  Draw  sheet 
1 2  Doctor's  towels  (per  ward) 
6  Round  towels  „ 

4  Table  covers  ,, 

6  Tea         ,,  ,, 


^  Cottage  Hospitals,  p.  231. 


JVA/?D  FURNITURE 


149 


6  Dusters  per  ward 
6  Shirts  ,, 

12  Finger  napkins  per  ward 
I  Nightingale  cloak 
I  Mattress  or  bed,  flock  or  horse- 
hair 
I  Bolster 
I  Feather  pillow 
I  Straw  palliasse 

Nurses  : 

1  Quilt  each  and  2  over 

3  Blankets  each 

3  Sheets  ,, 

2  Pillow  cases  ,, 

4  Towels  ,, 
6  Table  cloths  ,, 
6  Oil  baize  toilets              ,, 


I  Mattress,  horsehair  each 
I  (Hair)  bolster  ,, 

I  Feather  pillow  ,, 

Servants : 
I  Quilt  each  and  2  over 


3  Blankets 

3  Sheets 

2  Pillow  cases 

4  Towels 

3  Rollers 

1 2  Tea  cloths 
12  Dusters 
6  Table  cloths 

4  Oil  baize  toilets 

I  Mattress,  horsehair 
I  Hair  bolster 
I  Feather  pillow 


each 


CHAPTER  VII 

Disinfection 

The  disinfecting  process  or  apparatus  provided  within 
the  grounds  of  an  Isolation  Hospital,  as  well  as  the 
laundry  and  wash-house,  should  not  only  be  of  sufficient 
resource  to  meet  the  requirements  of  the  hospital, 
but  also  of  the  whole  district  to  which  the  hospital 
administers,  in  so  far  as  the  disinfection  of  infected 
articles  is  concerned.  The  disinfecting-room,  as  well 
as  the  laundry,  wash-house,  and  stores  for  disinfected 
washed  clothes,  should  therefore  be  out  of  the  range 
of  infection  from  the  hospital,  and  also  at  a  safe  distance 
from  the  wall  surrounding  the  hospital  grounds.  Forty 
feet  is  believed  to  be  a  safe  distance  from  the  wards 
and  area  wall. 

In  every  Isolation  Hospital  the  disinfection  or 
destruction  of  excretions,  refuse,  ward  clothing.,  etc., 
must  be  carried  out  from  day  to  day.  The  clothes 
worn  by  each  patient  on  admission  must  also  be 
disinfected  and  stored.  Before  a  patient  is  discharged 
he  must  be  thoroughly  washed  and  disinfected,  and 
provided    with   perfectly    clean    non- infected   clothes. 


DISINFECTION  151 


Every  hospital  ward  must  be  occasionally  emptied  of 
its  furniture,  beds,  and  bedding,  all  of  which  should 
be  thoroughly  disinfected  to  prevent  the  accumulation 
of  noxious  effluvia  by  continuous  occupancy.^ 

In  large  hospitals  the  provision  of  one  or  two 
"fallow"  wards  has  been  recommended  for  this 
purpose.  In  such  cases  one  or  two  wards  are 
always  empty  or  "fallow,"  and  undergoing  aeration, 
washing,  and  disinfection.  As  soon  as  this  is 
completed,  these  wards  may  be  used  and  other  wards 
emptied  for  the  same  purpose.  In  small  hospitals, 
such  as  I  have  under  consideration,  this  plan  is  not 
practicable,  but  probably  taking  one  year  with  an- 
other, the  benefit  of  the  "  fallow  "  ward  system  will  be 
so  far  secured  by  the  less  continuous  use  of  the  ward. 
In  small  hospitals  again,  the  same  wards,  the  same 
beds  and  bedclothes,  must  be  utilised  for  different 
infectious  diseases  at  different  times,  and  it  will  be 
absolutely  necessary,  every  time  a  change  is  made, 
that  the  wards  and  all  articles  contained  in  them,  as 
well  as  their  accessories,  should  be  thoroughly  dis- 
infected. In  addition  to  all  this,  the  disinfecting  and 
washing  resources  provided  should  be  able  to  cope 
with  any  extra  pressure  brought  about  through  in- 
fected articles  being  sent  in  from  any  of  the  dwelling- 
houses    in   the   surrounding   district   for   disinfection. 

1  Dr.  Mahomed  noticed  that  at  the  fever  hospital  at  Islington,  London, 
patients  suffering  from  scarlet  fever  recovered  better  after  the  wards  were  washed 
and  purified.  There  was  less  sloughing  and  glandular  abscesses.  Dr.  Howse 
of  Guy's  Hospital  noticed  something  similar  in  his  private  practice.  The  first 
case  treated  in  a  room  was  mild,  but  the  other  cases  were  more  severe  as  the 
room  got  saturated  with  infection. 


152  PREVENTION  OF  EPIDEMICS 

That,  by  the  adoption  of  proper  means,  articles  of 
clothing,  as  well  as  premises  and  furniture,  can  be 
rendered  free  from  infection  and  safe  for  use  or 
occupation,  has  been  proved  beyond  a  doubt.  The 
following  statement  by  Dr.  Gayton,  a  gentleman  who 
perhaps  has  had  more  experience  in  the  treatment  and 
management  of  infectious  diseases  than  any  other  now 
living,  is  of  importance,  as  bearing  on  this  question :  — 
"  I  have  no  doubt  as  to  the  possibility  of  rendering  a 
hospital  perfectly  free  from  infection.  .  .  .  On  15th 
October  1874  1695  cases  of  smallpox  had  been  re- 
ceived into  the  Homerton  Smallpox  Hospital.  It  was 
then  decided  that  scarlet  fever  patients  should  be  ad- 
mitted, and  accordingly  preparations  were  at  once  made 
for  their  treatment ;  1 22  of  this  class  passed  through  the 
wards  without  any  case  of  smallpox  arising.  Again, 
on  the  22nd  October  1875,  scarlet  fever  patients  were 
admitted,  49  in  all,  without  smallpox  appearing  (no 
case  of  variola  had  been  admitted  meanwhile).  On 
22nd  June  1876,  the  reception  of  smallpox  was  recom- 
menced— 620  being  treated  during  the  year  without 
scarlet  fever  being  diagnosed  amongst  them.  In 
1877,  1935  persons  suffering  from  smallpox  were  ad- 
mitted, and  in  1878,  964.  On  15th  March  enteric 
fever  cases  were  received,  the  total  number  being 
154.  Amongst  these  a  case  occurred  of  undoubted 
smallpox,  but  it  was  admitted  from  Deptford  Hospital, 
where  smallpox   was    treated,  and   it  is   a    matter  of 

^  Smallpox  and  Fever  Hospitals  Commission,   Evidence,   Questions  2682, 
2690,  and  2691. 


DISINFECTION  153 


doubt  as  to  which  hospital  should  be  credited  with  the 
origin  of  the  attack.  At  intervals  enteric  fever,  scarlet 
fever,  and  smallpox  patients  occupied  the  same  ward, 
the  same  beds,  and  the  same  clothing,  and  without 
any  evil  result  following.  Every  single  article  of 
clothing  was  passed  through  the  oven." 

In  the  hospital  referred  to,  however,  an  expen- 
sive disinfecting  apparatus  is  provided.  This  is  not 
practicable  in  every  hospital  in  small  towns  and  rural 
districts.  The  most  reliable  apparatus  at  present  pro- 
vided in  this  country  cannot  be  purchased  for  less 
than  ^100.  The  machine  requires  the  most  careful 
attention  and  skill  on  the  part  of  the  manipulator,  and 
indeed  the  upkeep  does  not  fall  far  short  of  the  same 
amount  per  annum.  Such  an  expenditure  being 
almost  prohibitive  in  many  districts,  it  remains  to 
be  considered  what  other  effective  means  may  be 
attainable. 

The  science  of  disinfection  has  made  consider- 
able progress  during  the  past  twenty  years.  I  have 
already  shown  how  the  agents  of  disease  have  been 
demonstrated  to  be  of  the  nature  of  micro-organisms, 
how  these  have  been  isolated,  made  to  grow  outside 
the  human  or  animal  body  on  various  media,  and  how 
it  was  proved  that  they  retained  their  power  of  pro- 
ducing disease  under  various  conditions.  The  micro- 
organisms of  various  diseases  have  been  also  subjected 
to  various  agents  with  a  view  to  find  out  the  best 
practicable  and  most  inexpensive  method  of  destroy- 
ing their  vitality,  with  a  special  view  of  discovering 


154  PREVENTION  OF  EPIDEMICS 

reliable  means  for  the  disinfection  of  infected  clothing 
and  other  articles. 

In    1886,   Dr.   Parsons  of  the  Local   Government 
Board,  in  conjunction  with  Dr.   Klein,  carried  out  a 
series  of  important  experiments,  with  a  view  to  discover 
the  effect  of  heat  in  destroying  the  micro-organisms 
of  disease.     For  this  purpose  they  selected  of  those 
micro-organisms  known  to  them  the  hardiest  and  most 
resistent  to  every  form  of  heat,  and  not  only  in  bacillar 
or  plant  form,  but  also  in  spore  or  seed  form,  in  which 
state  the  agents  of  some   infections  have  previously 
been  proved  to   retain  their  vitality  for  a  very  long 
time  and  under  very  unfavourable  conditions.     They 
reasoned  that   "such  arrangements  as  would  be  ade- 
quate to  destroy  these  '  infections '  might  be  trusted  to 
destroy  the    potency  of  infectious  matter   generally." 
The  following  were  the  infective  materials  employed : 
— (i)  Blood  of  a  guinea  pig,  dead  of  anthrax,  containing 
bacilhts  anthracis   without  spores — this  is  the  micro- 
organism which  causes  woolsorter's  disease  in   human 
beings  ;    (2)   Pure  cultivation  of  the  same  bacillus  in 
rabbit   broth  without    spores  ;  (3)   Cultivation  of  the 
same  bacillus  in  gelatine  with  spores,  this  being  the 
hardiest  form  in  which  this  bacillus  is  known  to  exist ; 
(4)  Cultivation  of  the  bacillus  of  swine  fever  in  pork 
broth  ;  (5)  Tubercular  pus  from  an  abscess  in  a  guinea 
pig  which  had  been  inoculated  with  tubercle.     This 
contained  the  bacillus  which   causes  consumption    in 
human  beings.     Unheated  portions  of  these  materials, 
as  well  as  portions  heated  to  different  temperatures, 


DISINFECTION  155 


were  tested  on  animals  in  all  cases,  in  the  experi- 
ments made. 

They  first  experimented  on  the  effect  of  dry  heat 
at  different  temperatures  on  these  materials,  and  they 
found  that  "the  spores  of  the  bacillus  anthracis  (the 
most  resistent  to  every  form  of  heat)  lost  their  vitality, 
or  at  anyrate  their  pathogenic  quality  (their  power  of 
producing  disease),  after  exposure  for  four  hours  to  a 
dry  temperature  a  little  over  the  boiling  point  of  water 
(212-21 6°),  or  for  an  hour  to  a  temperature  of  245°  Fahr. 
Non-spore-bearing  bacilli  of  anthrax  and  of  swine 
fever  were  rendered  inert  by  exposure  for  an  hour  to 
a  temperature  of  212-218°  Fahr.,  and  even  five  minutes 
exposure  to  this  temperature  sufficed  to  destroy  the 
vitality  of  the  former,  and  impair  that  of  the  latter." 

They  afterwards  experimented  with  boiling  water, 
or  water  mixed  with  a  very  small  quantity  of  common 
salt  (J  per  cent),  and  they  found  that  a  cultivation  of 
anthrax  bacillus  containing  spores  was  rendered  inert 
by  five  minutes  boiling  in  this  very  dilute  brine.  The 
above  results  being  so  satisfactory,  it  was  not  con- 
sidered necessary  to  repeat  the  experiments  with  the 
less-resisting  contagia  of  swine  fever  or  tubercle. 

Experiments  were  then  made  with  steam  at  the 
temperature  of  boiling  water  (212°  Fahr.).  Dr.  Parsons 
states  in  regard  to  these  :  "  The  results  of  the  above 
experiments  are  conclusive  as  to  the  destructive  power 
of  steam  at  212°  Fahr.  upon  all  the  contagia  submitted 
to  its  action  ;  in  one  instance  only  was  there  room  for 
suspicion  that  the  disinfection  had  not  been  complete — 


156  PREVENTION  OF  EPIDEMICS 

this  was  in  the  case  of  the  highly-resisting  spores  ex- 
posed to  steam  for  five  minutes  only.  On  the  other 
hand,  the  animals  inoculated  with  unheated  portions 
of  the  same  materials  all  died."  .  .  .  "In  view  of  the 
above  satisfactory  results,  it  was  not  deemed  necessary 
to  make  any  experiments  as  to  the  disinfecting  powers 
of  steam  at  higher  temperatures  or  under  pressure  ;  its 
efficiency  may  be  taken  for  granted." 

It  will  thus  be  seen  that  the  most  persistent  or 
the  most  tenacious  of  life  of  the  micro-organisms  of 
disease  can  be  destroyed  by  a  few  minutes  boiling  in 
water,  or  by  exposure  to  steam  at  212°  Fahr.  for  a  few 
minutes,  and  that  bacilli  which  do  not  bear  seeds  or 
spores  may  be  rendered  inert  by  exposure  for  one 
hour  to  even  a  dry  heat  of  2 1 2-2 1 8°  Fahr.  "  As  none  of 
the  infectious  diseases  for  the  extirpation  of  which 
measures  of  disinfection  are  in  practice  commonly 
required,  are  known  to  depend  upon  the  presence  of 
bacilli  in  a  spore-bearing  condition,  it  may  be  con- 
cluded that,  as  far  as  our  knowledge  goes,  their 
contagia  are  not  likely  to  retain  their  activity  after 
being  heated  for  an  hour  to  220°  Fahr." 

"  Of  diseases  affecting  the  human  species,  anthrax 
is  the  only  one  of  which  it  is  established  that  it  is 
connected  with  the  presence  of  micro-organisms 
possessing  this  persistent  form  of  spores."^ 

Articles  infected  by  any  of  the  infectious  diseases 
prevalent  in  this  country  can  therefore  be  disinfected 

^  Extract  from  Report  of  Medical  Officer  of  the  Local  Government  Board, 
1886  :  Dr.  Parsons,  p.  lo. 


DISINFECTION  1 5  7 


by  steam  at  212°  Fahr.,  by  boiling  in  water  for  a  few 
minutes,  or  by  being  heated  through  for  an  hour  in 
dry  heat  at  220°  Fahr. 

The  next  point  to  be  tested  was  the  rate  of 
penetration  of  dry  heat  and  steam  into  bulky  articles 
of  non  conducting  materials,  such  as  pillows,  mat- 
tresses, etc.  Dr.  Parsons  showed  by  experiments  with 
various  disinfecting  apparatus,  minutely  described  in 
his  report,  "how  difficult  it  is  to  secure  the  penetra- 
tion of  a  dry  heat  sufficient  for  disinfection  into  the 
interior  of  such  articles  as  a  pillow.  It  was  only 
effected  by  either  employing  a  very  high  degree  of 
heat,  or  by  continuing  its  employment  during  many 
hours,  the  length  of  exposure  compensating  for  a  lower 
degree  of  heat."  The  outside  was  often  scorched 
before  the  temperature  in  the  centre  of  the  pillow  was 
sufficient  to  destroy  infection.  If  heat  was  applied  by 
means  of  steam  instead  of  dry  heat,  he  found  that  the 
rate  of  penetration  was  much  in  favour  of  the  former. 
Dr.  Parsons  came  to  the  conclusion  that  "  it  cannot 
be  doubted  that  to  procure  the  penetration  by  heat  of 
bulky  articles  of  badly  conducting  material,  high- 
pressure  steam  is  the  2i^^rvt  par  excellence T 

The  following  experiment  among  many  others 
is  recorded  by  Dr.  Parsons.  "  Three  yards  of  flannel 
previously  dried  were  wrapped  round  a  registering 
thermometer,  making  a  roll  1 2  inches  long  by  4  inches 
broad.  This  was  placed  in  the  cylinder  before 
mentioned  and  exposed  for  ten  minutes  to  steam  at 
2 1 2°  [Fahr.]    The  thermometer  registered  212°  [Fahr.] 


iSS  PREVENTION  OF  EPIDEMICS 

The  same  roll  of  flannel,  after  drying,  was  placed  in  a 
hot-air  bath  of  pots,  and  exposed  for  an  hour  to  a 
temperature  of  212°  [Fahr.].  The  thermometer  inside 
then  registered  130°"  [Fahr,^]. 

Having  established  the  facts  that  exposure  of 
one  hour  to  dry  heat  of  220°  Fahr.,  or  five  minutes 
exposure  to  boiling  water  or  steam  at  212°  Fahr.,  was 
sufficient  to  destroy  the  infective  materials  of  the 
infectious  diseases  treated  in  Isolation  Hospitals,  and 
that  steam  penetrated  with  more  ease  and  certainty 
into  the  centre  of  bulky  articles,  the  next  point  for 
consideration  was  the  liability  to  injury  of  articles 
disinfected  by  heat. 

Dr.  Parsons  classified  the  ways  in  which  injury 
may  occur  to  various  articles,  into — (i)  scorching,  (2) 
overdrying,  (3)  fixing  of  stains,  (4)  melting  of  fusible 
substances,  {5)  alterations  in  colour,  (6)  shrinkage  and 
felting  together  of  woollen  materials,  (7)  wetting. 
He  found  that  "  overdrying  can  of  course  only  occur 
when  dry  heat  is  employed,  wetting  only  when  steam 
or  boiling  water  is  used.  Shrinkage  takes  place  more 
with  steam  than  with  dry  heat.  Scorching  is  more 
liable  to  occur  with  dry  heat  than  with  steam.  The 
other   occurrence   may    happen    with    heat    in    either 

1  The  experiments  with  steam  were  made  in  an  improvised  apparatus,  similar 
to  that  employed  in  Dr.  Koch's  researches.  It  consisted  of  a  tin  cylinder  14 
inches  long  by  4  inches  in  diameter,  wrapped  in  felt  to  diminish  loss  of  heat. 
In  the  bottom  a  hole  was  made,  and  by  means  of  corks  and  a  short  piece  of  pipe 
the  cylinder  was  connected  with  a  tin  flask  serving  as  a  boiler.  A  false  bottom 
was  fixed  in  the  cylinder  just  above  its  base,  with  a  view  to  the  more  even  dis- 
tribution of  the  heat.  The  upper  end  of  the  cylinder  was  closed  with  a  lid 
having  a  hole  in  the  centre,  just  large  enough  for  the  escape  of  steam,  and  the 
introduction  of  a  thermometer.      '^^&  Report,  ^.  lo-ii. 


DISINFECTION  159 


moist  or  dry  form."     It  would  appear,  however   that 
exposure  to  temperatures  which  have  been  proved  to 
destroy  infection  does  not  cause  much  injury  to  the 
majority  of  articles.     Thus  white  flannel  was  exposed 
to  steam  at  212°  for  half  an  hour,  and  it  shrank   5.8 
per  cent  of  its  length,  and  got  a  slight  yellowish  tinge. 
On  being  simply  washed  it  shrank  6.6  per  cent,  with  a 
very  slight  change  of  colour.     When  boiled  in  water 
for  half  an  hour,  it  shrank  8.4  per  cent,  and  took  a 
dirty  yellowish  tinge.     Gloves,  however,  were  spoiled 
by  exposure  for  five  minutes  to  steam  at  the  tempera- 
ture of  boiling  water,  so  were  shoes  and  other  leather 
articles.     Such  articles,  however,  were  not  affected  by 
exposure  to  dry  heat  of  220°.     A   felt   hat   was   not 
altered  by  exposure  for  one  hour  to  a  dry  heat  of  even 
250°.      Dr.  Parsons  states  that  "  the  colour  and  tenacity 
of  white  flannel  were  affected  by  even    a   moderate 
exposure  to  heat ;  blankets  also  were  deteriorated  in 
a  minor  degree.       Cotton,  black  cloth,  and  silk  were 
little  affected  by  temperatures  under  300°  .   .  .   Leather 
will  bear  a  moderate  application  of  dry  heat,  but  is 
utterly  disorganised  by  a  very  short  exposure  to  steam." 
Stains  got  fixed  by  a   heat  of  212°    Fahr.,   whether 
dry,    or   steam,   or  boiling  water.     According  to   M. 
Vallin,  however,  a  washed  piece  of  flannel  exposed  to 
a  temperature  of  230°  Fahr.  for  three  hours  did  not 
show  any  difference  in  colour  from  another  portion  not 
heated,  of  the  same  (washed)  material.     Dr.  Russell  of 
Glasgow  ^  states  in  regard  to  the  application  of  heat 

1   Glasgow  Medical  Journal,  Dec.  1884,  pp.  404,  405. 


i6o  PREVENTION  OF  EPIDEMICS 

for  the  disinfection  of  bed  and  body  clothing,  and 
bedding,  "  Yet  it  is  also  true  that  this  disinfectant  is 
the  most  difficult  of  all  to  apply  without  injury  to  the 
textures  submitted  to  it.  The  material  is  derived 
from  many  sources,  animal  and  vegetable,  and  varies 
therefore  in  the  power  of  resisting  heat.  The  value 
of  the  manufactured  article  depends  sometimes  on 
form  and  elasticity,  which  may  be  lost  through  heat, 
or  on  colour,  which  may  be  impaired.  Every  one 
knows  that  blankets  and  other  woollen  articles  cannot 
be  boiled  without  serious  injury.  Even  the  most 
cautious  washing  changes  gradually  the  white  fleecy 
new  blanket  into  the  yellow,  dense,  bare,  comparatively 
comfortless  old  one.  With  cottons  and  linens  there 
is  no  trouble.  Wool,  hair,  and  feathers  are  most 
troublesome.  They  all  depend  for  their  value  and 
utility  upon  form  and  elasticity,  which  again  depend 
not  only  upon  the  hygrometric  moisture,  but  upon  the 
presence  of  animal  fats." 

Koch  and  Wolf hugel  ^  were  asked  to  advise  the 
German  Government  in  1881  as  to  the  efficacy  of 
heat  for  disinfection.  They  experimented  on  the 
degree  of  heat  necessary  for  the  destruction  of  various 
micro-organisms  on  the  same  lines  as  Drs.  Parsons 
and  Klein,  and  they  came  to  the  conclusion  that 
bacteria  free  from  spores  cannot  withstand  an  ex- 
posure of  half  an  hour  to  a  temperature  a  little  over 
212"  Fahr.  in  hot  air,  but  that  a  dry  heat  of  284°  Fahr., 
continuously  applied  for  three  hours,  was  necessary  to 

1  Mittheilungen  ans  dem  Kaiserlichett  Gesimdheitsamie,  Berlin,  1881. 


DISINFECTION  i6i 


destroy  the  spores  of  bacilli.  With  steam,  however, 
they  found  that  five  minutes  exposure  at  a  temperature 
of  2  12°  Fahr.  sufficed  to  destroy  the  spores  as  well  as 
non-spore  bearing  bacilli.  They  also  found  that  with 
steam  the  heat  penetrated  into  the  interior  of  bulky 
articles  much  more  quickly  than  with  dry  heat.  With 
hot  air  or  dry  heat,  they  found  that  after  an  exposure 
of  three  or  four  hours  to  a  temperature  of  284°  Fahr., 
small  bundles  of  clothes,  pillows,  etc.,  were  not  dis- 
infected, and  that,  at  that  temperature,  most  materials 
were  more  or  less  injured. 

The  experiments  of  Drs.  Parsons  and  Klein  there- 
fore confirmed  those  carried  out  by  Koch  and  Wolf- 
hligel  two  years  before.  Yet  in  the  practical  applica- 
tion of  heat  to  disinfection  many  difficulties  are  met 
with.  Although  articles  consisting  of  hair,  cotton,  and 
linen  may  be  subjected  to  the  required  degree  of  any 
form  of  heat,  the  wearing  qualities  of  feather  and 
woollen  articles  may  be  impaired  in  many  ways. 
While  steam  or  boiling  destroys  leather,  dry  heat 
causes  more  scorching  of  other  articles,  and  its  slow 
penetration  renders  its  use  uncertain  and  ineffective  in 
the  disinfection  of  bulky  bad-conducting  material. 

Some  chemical  poisons  have  also  been  found  suit- 
able  for  the  destruction  of  the  micro-organisms  of 
disease.  In  the  application  of  these,  however,  the 
strength  of  the  solution  or  vapour  used,  the  duration 
of  its  action,  the  nature  of  the  substance  with  which 
the  micro-organisms  are  mixed,  as  well  as  the  nature 
of  the  agents  of  infection,  must  be  considered.     The 

M 


1 62  PREVENTION  OF  EPIDEMICS 

spores  of  bacilli  are  more  resistent  than  the  bacilli 
themselves  to  the  action  of  poisons  in  the  same 
manner  as  to  the  action  of  heat.  The  medium  in 
which  micro  -  organisms  may  be  embedded,  or  the 
substance  by  which  they  are  surrounded,  may  exhaust 
the  destructive  power  of  the  poison  and  prevent  it 
from  reaching  them.  Corrosive  sublimate,  which  was 
found  by  Koch  to  be  the  most  active  bacterial  poison, 
is  precipitated  by  albuminous  fluids.  This  renders 
the  poison  insufficient  for  the  disinfection  of  tubercular 
sputum.  In  non-albuminous  fluids,  however,  Fltigge 
states  that  i  part  to  looo  kills  even  all  spores  in  a 
few  minutes.  Koch  also  found  that  a  5  per  cent 
watery  solution  of  carbolic  acid  destroyed  spores 
between  the  first  and  second  day.  He,  however, 
found  "that  sulphurous  acid  gas,  even  when  as  con- 
centrated as  possible  —  a  degree  of  concentration 
which  cannot  be  attained  in  practice  —  only  kills 
spores  imperfectly,"  and  that  its  action  on  non-spore 
bearing  bacteria  was  uncertain  when  present  in  10  per 
cent  by  volume,  owing  to  its  defective  penetration,  and 
to  the  fact  that  objects  subjected  to  it  must  be  pre- 
viously moistened.  The  same  is  true,  although  to  a 
less  extent,  of  chlorine  and  bromine  gases. 

5  per  cent  of  permanganate  of  potash,  and  i 
per  cent  of  osmic  acid  in  water  destroyed  the  organisms 
on  the  first  day. 

The  use  of  dry  heat  may  thus  be  set  aside 
as  inefficient  and  unsatisfactory.  The  remain- 
ing agents,  such  as  steam,   boiling  water,   and  some 


DISINFECTION  163 


chemical  poisons  and  gases,  may  be  used  under  vary- 
ing circumstances.  The  efficiency  of  chemical  fluids 
of  known  strength  is  regarded,  and  must  necessarily 
be  regarded,  as  uncertain  ^  under  various  conditions. 
Their  use  has  also  been  looked  upon  more  or  less  as 
unnecessary.^  The  proper  application  of  solutions  of 
carbolic  acid  or  corrosive  sublimate  of  sufficient 
strength  has  not,  so  far  as  I  am  aware,  been  proved 
to  be  inefficient  in  destroying  the  agent  of  infection  in 
the  case  of  any  of  the  ordinary  infectious  diseases  pre- 
valent in  this  country.  Common  sense  is  sufficient  to 
show  that  masses  of  solid  or  semi-solid  matter,  such 
as  faeces,  or  large  lumps  of  dried  pus,  or  smallpox 
scales,  may  be  impenetrable  to  these  fluids  in  the 
strengths  used,  and  within  the  time  generally  allowed 
in  ordinary  everyday  practice.  That,  however,  does 
not  prove  that  the  small  epithelial  scales  and  micro- 
scopic dust  within  which  the  micro-organisms  of  infec- 
tious diseases  must  be  commonly  embedded  are  not 
affected  by  these  agents.  These  scales  and  particles 
are  highly  hygroscopic.  They  easily  absorb  moisture. 
They  are  softened  by  water,  and  being  so,  the  organ- 
isms contained  within  them  must,  if  sufficient  time  be 
allowed,  be  exposed  to  the  poison  dissolved  in  the 
water.  Further,  these  chemical  fluids  are  dissolved  in 
such  strengths  as  would  destroy  the  most  resistent 
spores  known,   although  none  of  the   agents   of   the 


1  Disinfection  by  Heat,  Dr.  Parsons,  p.  18. 

2  "  On  Disinfection,"  Dr.  Russell,  Glasgow  Medical  Journal,  1884,  pp.  406, 
407. 


1 64  PREVENTION  OF  EPIDEMICS 

infectious  diseases  prevalent  in  this  country  have  yet 
been  proved  to  propagate  by  means  of  spores. 

The  following  extracts  from  an  article  by  Dr. 
Russell  of  Glasgow,  and  from  Reports  by  Dr.  Gayton 
of  the  North  -  Western  District  Hospital,  London, 
point  to  the  utility  of  corrosive  sublimate  solution,  at 
least  for  some  purposes.  Dr.  Russell  states:  "We 
have  during  the  last  ten  years  washed  in  the  same 
washing-house  over  a  million  of  articles  of  every  sort, 
infected  by  every  variety  of  contagium  known  in  this 
country.  Everything  has  been  done  exactly  as  any 
good  housewife  would  do  it,  only  in  a  place  provided 
for  the  purpose,  and  with  ample  supply  of  water  and 
steam,  and  recently  with  mechanical  aid.  Blankets 
and  woollen  articles  have  not  been  boiled ;  all  others 
have.  The  most  crucial  fact  is  this,  that  there  has 
never  been  a  single  case,  or  suspicion  of  a  case,  of 
interchanged  disease,  e.g.  of  smallpox,  appearing  in  a 
house  from  which  clothes  had  been  removed  on 
account  of  scarlet  fever  or  typhus.  In  short,  I  am 
convinced  that  in  every  case  the  result  was  obtained 
for  which  the  operation  of  washing  was  undertaken. 
The  only  defect  is  this,  that  the  washerwomen  must 
handle  the  articles  before  disinfection  or  drowning  of 
the  contagia  in  water,  and  therefore  are  occasionally 
infected.''^ 

Dr.  Gayton  informs  me  that  before  he  took  charge 
of  the  North -Western  District  Hospital  the  nurses 
and   assistant    nurses    were    frequently  attacked   with 

1   Glasgow  Medical  Journal,  18S4,  vol.  ii.  p.  409. 


DISINFECTION  165 


typhoid  fever.  At  that  time  the  soiled  Hnen,  as  soon 
as  it  was  taken  off  the  beds  and  patients,  was  stored 
in  a  box  in  a  room  off  the  ward.  It  was  afterwards 
sorted  by  the  nurse  or  assistant  nurse,  and  sent  to  the 
laundry.  The  doctor  attributed  the  outbreaks  of  fever 
among  the  staff  to  the  inhalation  of  infected  dust 
during  the  process  of  sorting  this  soiled  linen,  and  he 
advised  the  hospital  committee  to  construct  tanks  com- 
municating by  a  shoot  with  the  wards.  Into  these 
tanks  he  put  a  solution  of  corrosive  sublimate  of 
I -1000,  and  gave  instructions  that  all  articles  of 
clothing  should  immediately  be  steeped  in  them. 
Since  that  time  the  staff  have  not  suffered  from 
typhoid  fever,  as  the  following  extracts  from  his  report 
show  :  "  I  have  much  satisfaction  in  stating  that  not 
a  single  case  of  enteric  fever  has  occurred,  and  the 
exemption  I  believe  to  be  mainly  owing  to  your  wil- 
lingness and  co-operation  in  allowing  me  to  have  con- 
structed the  means  whereby  all  the  foul  linen  is 
instantly  removed  from  the  wards  into  tanks  contain- 
ing an  antiseptic  fluid,  in  which  it  remains  until  trans- 
ferred to  the  laundry.  If  the  fresh  stools  of  persons 
suffering  from  typhoid  fever  are  capable  of  infecting 
those  in  immediate  contact,  and  of  which  I  had  con- 
clusive proof  some  time  ago,  the  placing  of  linen 
soaked  with  discharges  in  receptacles  excluded  from 
air,  allowed  to  remain  many  hours,  and  then  freely 
handled  for  the  purpose  of  sorting,  would  appear  to  be 
a  most  ready  way  of  communicating  the  disease."  ^    In 

^  Report  of  Medical  Superintendent  of  North- Western  District  Hospital,  1884.   , 


1 66  PREVENTION  OF  EPIDEMICS 

1893  Dr.  Gayton  reports  :  "  One  case  also  was  affected 
by  enteric  fever  undoubtedly  contracted  in  the  dis- 
charge of  her  duties,  the  first  since  my  connection 
with  the  hospital." 

The  steeping  of  the  clothes  in  pure  water  might 
have  answered  the  same  purpose  in  so  far  as  the  fixing 
of  dust  and  the  volatile  agents  of  disease  is  con- 
cerned, but  in  that  case  the  water  would  be  charged 
with  the  micro-organisms  of  disease,  and  might  itself 
become  a  medium  of  infection.  If,  however,  the 
steeping  solution  is  destructive  to  bacteria  of  all  kinds, 
it  will  answer  the  double  purpose  of  fixing  volatile 
infection,  and  destroying  at  least  part  of  it,  while  no 
injury  whatsoever  results  to  the  articles  steeped.  At 
the  same  time  the  fixing  of  stains  is  prevented,  which 
otherwise  might  result  from  boiling. 

At  the  N.W.  District  Hospital  of  the  Metropolitan 
Asylums  Board  all  washable  articles  after  being  steeped 
are,  according  to  Dr.  Gayton,  sent  to  the  laundry  and 
boiled  for  twenty  minutes.  All  the  clothes  from  the 
enteric,  scarlet  fever,  and  diphtheria  wards  are  then 
mixed  together  in  the  process  of  washing  and  drying. 
The  clothes  for  the  different  diseases  are  marked,  and 
when  ready  are  returned  to  the  different  depart- 
ments. There  has  been  no  interchange  of  disease 
between  the  wards.  In  a  letter  from  Dr.  Russell, 
quoted  by  Dr.  Parsons  in  his  report,  he  states  : 
"  For  many  years  I  have  used  no  other  disinfect- 
ing method  for  washable  articles  than  boiling  one 
quarter  to  three  quarters  of  an   hour  by  steam  with 


DISINFECTION  167 


soap  and  soda.  I  concluded  this  was  sufficient, 
because,  though  we  threw  smallpox,  typhus,  enteric, 
scarlet  fever,  etc.,  all  into  one  witches'  cauldron,  I 
never  heard  of  any  inter-communication  or  continuity 
of  infection."  ^ 

From  the  above  it  may  be  seen  that  reliable  means 
for  the  disinfection  of  clothes  and  other  articles  may 
be  brought  within  the  reach  of  even  the  most  isolated 
rural  district.  Both  in  small  towns  and  rural  districts, 
Isolation  Hospitals  should  be  erected  in  more  or  less 
isolated  localities.  A  spacious  drying  or  airing  green 
should  be  provided  in  proximity  to  the  laundry,  within 
the  hospital  ground.  The  laundry  should  in  size  and 
equipment  be  in  excess  of  the  requirements  of  the 
hospital.  A  large  boiler  should  be  provided  in  it,  in 
which  all  clothes  made  of  cotton  or  linen  should  be 
boiled  after  they  have  been  steeped  in  a  solution 
of  corrosive  sublimate  for  at  least  one  day.  The 
disinfecting  room  should  be  provided  with  a  tank 
containing  a  solution  of  corrosive  sublimate  i-iooo 
for  this  purpose.  This  will  prevent  the  fixing  of 
stains,  it  will  lessen  the  danger  to  the  washerwomen 
arising  from  breathing  infected  dust,  and  it  will  at 
least  partially  disinfect  the  clothes.  The  disinfecting 
chamber  should  also  be  provided  with  a  cheap  but 
reliable  apparatus  for  the  submission  of  such  articles 
as  cannot  be  boiled  to  the  action  of  steam.  An 
apparatus  on  the  model  of  the  cylinder  used  by  Koch, 
but  correspondingly  larger,  might  be  constructed  for  a 

1  Disinfection  by  Heat,  Dr.  Parsons,  p.  10. 


1 68  PREVENTION  OF  EPIDEMICS 

small  amount.  Fltigge  ^  describes  a  very  simple  and 
cheap  apparatus  used  in  Gottingen,  and  which  acted 
extremely  well.  It  is  made  in  two  sizes  :  one  for  the 
disinfection  of  portions  of  clothing  or  linen,  and  costs 
^7  :  los.  ;  the  other  is  of  sufficient  size  for  the  dis- 
infection of  mattresses,  and  costs  £1-^.  Dr.  Fliigge 
considers  that  such  machines  should  be  round,  or 
nearly  round,  to  provide  against  imperfect  disinfection 
in  corners.  He  also  states  that  it  was  definitely 
proved  by  numerous  experiments  in  Koch's  laboratory, 
and  confirmed  by  Wolff,  that  very  large  objects,  such 
as  balls  of  twenty-two  blankets,  are  completely  dis- 
infected by  exposure  for  one  to  two  hours  to  a  current 
of  steam  at  212°  Fahr.  The  time  of  exposure  to  this 
temperature  must  be  reckoned  from  the  time  that  the 
steam  issues  from  the  aperture  provided  for  its  exit 
at  a  temperature  of  212°  Fahr.  It  is  necessary  to 
have  a  current  of  steam  passing  through  the  clothes. 
If  this  is  attained  it  is  not  necessary  to  have  steam 
under  pressure  to  act  as  an  efficient  germicide  or  for 
the  penetration  of  bulky  articles.  Dr.  Parsons  has 
pointed  out  that  when  steam  enters  into  the  interstices 
of  a  cold  body  it  undergoes  condensation  in  imparting 
its  latent  heat  to  the  body,^  that  when  condensed  it 
occupies  but  a  small  portion  of  its  former  space,  and 
that  in  this  way  a  series  of  successive  vacua  are  formed 
into  which  a  fresh  supply  of  steam  enters  until  the 
whole  mass  is  penetrated.      If  the  materials  are  only 

1  Micro -orgajiisj/is,  Ijy  Dr.  C.  Fliigge,  j^p.  665,  773. 
^  Report  oil  Disinfection  by  Ileal,  p.   18. 


DISINFECTION  169 


moistened  by  steam  they  can  be  dried  in  a  short  time. 
It  is  only  where  they  are  soaked  with  water  from  the 
condensation  of  the  steam  on  the  sides  or  top  of  an 
apparatus  that  soakage  is  Hable  to  occur.  This  can 
be  prevented  by  simple  contrivances  described  by 
Flugge^  in  his  description  of  the  apparatus  used  in 
Gottingen.  The  subsequent  drying  of  articles  exposed 
to  steam  is  not  such  a  pressing  question  in  small 
communities  as  in  large  cities,  where  spacious  drying 
greens  are  not  so  easily  obtained,  and  loss  of  time  more 
considered.  For  such  communities  as  can  afford  to 
provide  an  apparatus  where  superheated  steam  under 
pressure  is  used,  such  as  the  Washington  -  Lyons 
patent  apparatus,  there  appears  to  be  no  doubt  what- 
ever of  its  superiority.  The  most  delicate  fabrics, 
as  well  as  the  most  bulky,  can  be  disinfected  with  the 
greatest  certainty,  and  with  the  least  injury,  trouble,  or 
loss  of  time.  This  apparatus,  however,  is  at  present 
so  expensive  that  it  cannot  be  purchased  by  small 
communities.  Where  no  steam  apparatus  of  an 
efficient  nature  is  provided,  disinfection  of  such  articles 
as  mattresses  and  blankets,  which  cannot  be  boiled, 
can  be  carried  out,  although  with  greater  trouble  and 
loss  of  time.  Hair  mattresses  should  be  opened  and 
the  ticks  and  hair  soaked  in  corrosive  sublimate 
solution,  and  subsequently  boiled  in  water.  The 
blankets  should  also  be  soaked  in  the  same  solution 
and  thoroughly  washed.  After  washing  they  should  be 
well   dried  and  exposed  to  air  and  sunlight  for  some 

1  Fliigge  on  Micro-organisms,  pp.  774,  775- 


I70  .        PREVENTION  OF  EPIDEMICS 

days.  To  enable  this  to  be  carried  out  without  interfer- 
ing with  the  use  of  the  hospital,  an  extra  supply  of 
blankets  and  mattresses  may  be  required.  Thorough 
washing  without  boiling  has  been  found  sufficient  for 
disinfection,  by  Dr.  Russell  of  Glasgow,  for  blankets 
and  woollen  articles. 

Boots  and  other  leather  articles,  as  well  as  hats, 
should  be  exposed  to  dry  heat.  Ordinary  boots,  as 
made  in  this  country,  will  not  stand  long  soaking  in 
corrosive  sublimate  solution.  In  the  absence  of  an 
efficient  disinfecting  apparatus,  carpets  and  stuffed 
furniture  should  be  thoroughly  beaten  and  exposed 
for  some  days  to  the  air  and  sunlight.  All  wooden 
and  other  articles  of  furniture  and  household  use  should 
be  washed  with  corrosive  sublimate  solution  and  after- 
wards scrubbed  with  soap  and  water.  The  same 
process  applies  to  walls,  windows,  floor,  and  doors. 

Appended  is  a  copy  of  the  instructions  for  dis- 
infection issued  by  Dr.  Collie  of  the  Homerton  Fever 
Hospital. 

As  soon  as  a  case  of  infectious  disease  is  removed 
to  a  hospital  it  is  the  duty  of  the  local  authority  to 
see  that  the  house  furniture  and  clothing  are  thoroughly 
disinfected.  This  requires  much  care  and  close  super- 
vision on  the  part  of  the  officers  appointed  to  see  it 
carried  out.  Many  difficulties  are  met  with,  more 
particularly  in  the  case  of  the  poor.  A  large  family, 
inhabiting  perhaps  one  or  two  apartments,  without  any 
other  place  of  abode,  cannot  well  be  turned  out  on  the 
roadside  until  the  house   is  thoroughly  gutted  of  its 


DISINFECTION  171 


contents  and  made  perfectly  safe  for  use.  The  clothes 
they  wear  should  be  disinfected,  as  well  as  the  bed- 
clothes in  which  they  sleep.  From  what  I  have 
already  stated  it  will  be  seen  that  this  is  a  process 
which  will  take  many  hours,  perhaps  a  day  or  two,  to 
complete.  If,  however,  as  much  of  the  infected 
clothing  as  could  be  spared  be  immediately  conveyed 
to  the  hospital  disinfecting  chamber  and  laundry,  and 
as  much  of  the  furniture,  etc.,  as  could  be  spared  be 
washed  and  turned  out  of  doors  for  exposure  to  the 
air,  the  infected  apartment  or  house  could  be  gradu- 
ally disinfected  without  excessive  hardship  or  incon- 
venience. With  the  assistance  of  one  or  two  women 
the  Sanitary  Inspector  could  see  the  work  completed 
within  a  reasonable  time,  and  without  undue  friction. 


Instructions  for  Disinfection  of  Homerton  Fever 
Hospital  after  being  used  as  a  Smallpox  Hospital. 

Wards,  etc. — i.  Wards,  including  nurses'  sitting-rooms,  sculleries, 
bath-rooms,  closets,  lavatories,  linen  cupboards,  and  linen  shoots,  to 
have  their  windows,  doors,  chimneys,  and  ventilators  completely 
closed,  and  to  be  emptied  of  all  movables,  excepting  the  blinds 
and  the  windows. 

2.  Then  burn  sulphur  in  an  atmosphere  of  steam  for  forty-eight 
hours,  so  as  to  permeate  all  the  above  mentioned  places. 

3.  The  windows  having  been  entirely  taken  out,  the  wards  and 
adjoining  rooms  are  to  be  exposed  for  fourteen  days  to  wind  and 
weather. 

4.  Remove  wash  from  ceiling,  and  then  whitewash  it.  Wash 
well  down  the  walls.  All  woodwork  to  be  thoroughly  washed  with 
soap  and  water,  and  the  floors  to  be  well  scrubbed.  The  walls  and 
woodwork  should  be  washed  well,  at  least  twice.     After  the  paint- 


172  PREVENTION  OF  EPIDEMICS 

ing,  the  floors  should  be  well  scrubbed  three  times,  at  intervals 
of  three  days.  The  hoppers  and  ventilators  should  be  specially 
looked  to. 

5.  Now  fix  the  windows,  new  sash-lines  having  been  supplied, 
and  commence  painting,  which  should  consist  of  at  least  three  coats. 

Fur]iiture. — i.  The  Venetian  blinds  to  be  taken  to  pieces,  and 
well  washed  with  soap  and  water,  dried  in  the  open  air,  and  re- 
painted, new  tapes  and  cords  being  supplied. 

2.  Bedsteads  to  be  taken  to  pieces,  and  well  washed  and  re- 
painted.    Sacking  to  be  washed  and  dried  in  the  open  air. 

3.  Beds,  pillows,  and  bolsters  to  be  emptied,  and  the  feathers  to 
be  washed  with  super-heated  steam  at  a  temperature  of  300°  for  twenty 
minutes,  and  dried  for  three  hours  at  a  temperature  of  250°.  All 
the  linen,  ticks,  blankets,  counterpanes,  draw  sheets,  shirts,  chemises, 
night-dresses,  towels,  handkerchiefs,  nightingales,  and  squares,  to  be 
steeped  in  fresh  water  one  week,  the  water  to  be  three  times  changed, 
then  to  be  boiled  in  different  waters  twice,  and  afterwards  washed 
and  dried  in  the  open  air,  but  the  blankets  and  nightingales  are  to 
be  subjected  to  a  dry  heat  of  230°,  and  not  boiled. 

4.  Night  stools,  bed-tables,  chairs,  bed-boards,  tables,  cupboards, 
presses,  and  racks  to  be  exposed  in  the  open  air  for  fourteen  days, 
then  well  scrubbed  with  soap  and  warm  water,  roughly  wiped,  and 
left  to  dry  in  the  open  air. 

5.  The  seats  of  the  night  stools  and  the  seats  of  all  the  water- 
closets  to  be  planed. 

6.  All  sinks,  sluice-pans,  and  closets  to  be  flushed. 

7.  Crockery  and  medicine  bottles  to  be  thoroughly  washed  in 
boiling  water.  The  feeders  in  particular  to  be  boiled,  and  the 
spouts  cleaned  out  with  a  brush. 

8.  All  brooms,  brushes,  scrubbing-brushes,  knee-rests,  flannels, 
dusters,  and  sponges  used  in  the  smallpox  period,  and  any  tow, 
lint,  or  cotton-wool  which  may  have  been  in  the  wards,  to  be 
destroyed ;  also  all  mats,  and  oilcloths,  and  carpets  in  the  wards,  or 
the  sitting-rooms  of  the  nurses. 

9.  Slop-pails  and  tubs  to  be  steeped  in  fresh  water  for  twenty-four 
hours,  exposed  to  wind  and  rain,  washed  in  warm  water  and  soap, 
and  dried  in  the  open  air  and  re-painted ;  all  rags  and  cloths  used  in 
connection  with  these  to  be  destroyed. 

Books,  papers,  toys,  etc.,  to  be  destroyed  or  sent  to  a  smallpox 
hospital. 


DISINFECTION  173 


Clothing. —  I.  Men's  and  women's  underclothing  to  be  steeped  in 
fresh  water  for  a  week,  twice  changed,  then  washed  and  dried  in  the 
open  air.  It  would  be  desirable,  however,  to  send  these  things  to  a 
smallpox  hospital  for  use,  as  they  do  not  stand  boiling  well. 

2.  Boots  and  shoes  used  by  smallpox  patients  to  be  sent  to  a 
smallpox  hospital  or  destroyed. 

3.  So  far  as  possible  the  clothing  of  officers,  nurses,  and  servants, 
worn  in  a  smallpox  ward,  to  be  steeped  in  fresh  water  for  a  week, 
then  washed,  boiled,  and  dried  in  the  open  air.  Clothing  so  worn 
which  cannot  be  so  treated  to  be  destroyed. 

Receiving  Rooms. — i.  To  be  treated  in  the  same  way  as  the 
wards,  but  new  baths  to  be  supplied. 

2.   New  carrying  chairs  to  be  supplied. 

General. —  i.  All  the  furniture  in  the  Asylum,  other  than  that  in 
the  wards,  to  be  cleaned  in  the  ordinary  way. 

2.  The  rooms  and  offices  of  officers,  nurses,  and  servants,  where 
paper  exists,  to  be  re-papered  after  the  removal  of  old  paper ;  wood- 
work to  be  washed  and  re-painted,  and  in  other  respects  cleaned  in 
the  ordinary  way. 

3.  Carpets  and  curtains,  beds,  bedding,  sheets,  hnen  generally, 
and  blankets,  and  all  furniture  in  officers'  and  servants'  rooms,  to  be 
thoroughly  cleaned. 

4.  All  rooms,  passages,  corridors,  pantries,  store-rooms,  linen- 
rooms,  stairs  and  staircases,  water-closets,  lavatories,  and  bath-rooms, 
in  the  administrative  departments,  to  be  well  washed  as  to  the  wood 
and  stone-work,  and  the  wood-work  to  be  re-painted,  and  white  or 
lime-washed,  where  such  was  the  case  before. 

5.  Mortuary  and  post-mortem  room  to  be  fumigated  with  sulphur 
and  steam,  well  washed  down,  exposed  to  the  atmosphere,  and  re- 
painted. 

Kitchen. — Well  washed,  exposed  to  the  atmosphere,  lime-whited 
and  re-painted.  All  utensils  employed  there  to  be  thoroughly 
cleaned. 

Stezuard's  Departmejit. — Store-rooms  and  offices  to  be  thoroughly 
cleaned  in  the  ordinary  way. 

Matron' s  Department,  Linen  and  Store-rooms. — Simple  cleaning. 

Laundry. — Simple  cleaning. 

Disinfecting  Chambers. — Simple  cleaning. 

Patients'  Clotlies  Rooms. — Wooden  framework  to  be  taken  out 


174  PREVENTION  OF  EPIDEMICS 

and  burnt,  to  be  thoroughly  fumigated  with  sulphur  and  steam, 
exposed  to  the  air  for  fourteen  days,  well  washed,  and  wood-work  re- 
painted. 

Dust  holes  and  Dust  shoots. — To  be  cleaned. 

Roads. — Fresh  gravel. 

In  a  word,  whatever  has  been  in  contact  with  smallpox  must, 
if  possible,  be  cleaned ;  and  what  cannot  be  cleaned,  must  be  got 
rid  of. 


CHAPTER    VIII 

Remarks  on  Hospital  Management — Ambulances 

The  efficient  management  of  Isolation  Hospitals,  with 
due  regard  to  economy,  is  a  matter  of  considerable 
difficulty.  Every  hospital,  however  small,  should  be 
under  the  management  of  a  committee  who  should  be 
responsible  to  the  Local  Authority  for  the  expenditure 
incurred  in  its  upkeep  and  maintenance. 

Scattered  communities  isolated  from  populous 
centres  suffer  less  from  outbreaks  of  infectious  disease. 
In  such  places  a  hospital  might  be  empty  for  a  con- 
siderable time.  In  small  towns,  and  even  rural 
districts  in  frequent  communication  with  towns,  cases 
of  infectious  diseases  of  one  kind  or  another  keep 
breaking  out  continually.  The  question  of  providing 
a  temporary  or  permanent  staff  for  Isolation  Hospitals 
is  therefore  worthy  of  consideration. 

In  England,  patients,  if  able  to  pay,  may  be  charged 
by  the  Local  Authority  for  medical  attendance  and 
maintenance  during  the  time  they  are  isolated  in  their 
hospitals.  In  Scotland,  however,  the  Local  Authority 
has  no  such  power.  The  expense  must  be  levied  on 
the  ratepayers  as  a  whole.      In  many  places  in  Eng- 


176  PREVENTION  OF  EPIDEMICS 

land  a  medical  practitioner  continues  his  attendance 
on  his  patient  after  his  removal  to  an  Isolation  Hos- 
pital, and  receives  his  usual  fees.  In  small  towns  or 
rural  districts  where  an  Isolation  Hospital  is  not  suffi- 
ciently large  to  require  the  services  of  a  resident 
medical  officer,  there  is  much  to  be  said  in  favour  of 
this  system.  If  the  medical  officer  of  health  is  also 
the  sole  hospital  doctor,  and  is  also  allowed  to  practise 
in  the  district,  other  medical  men  may  hesitate  to 
advise  their  patients  to  go  into  the  hospital.  By  doing 
so  they  incur  some  pecuniary  loss,  and  they  increase 
the  influence  of  a  rival  practitioner.  Patients  also 
naturally  follow  the  advice  of  their  own  family 
physician,  and  would  prefer  to  continue  under  his  care 
in  the  hospital  as  well  as  at  home.  If  medical 
practitioners  resident  in  a  district  are  allowed  to 
attend  on  their  own  patients  in  a  hospital,  there  is  not 
the  same  necessity  of  appointing  a  medical  officer  at  a 
fixed  salary.  Under  such  a  system  practitioners  are 
paid  only  when  their  services  are  required,  whereas 
by  appointing  one  man  with  a  fixed  salary,  he 
receives  payment  whether  the  hospital  is  used  or  not. 
It  would  be  very  undesirable  to  have  a  large  number 
of  medical  men  visiting  a  hospital  daily.  That,  how- 
ever, would  not  occur.  Where  a  large  number  of 
medical  men  are  to  be  found,  there  must  also  be  a 
large  population.  A  large  population  would  require  a 
hospital  of  such  a  size  as  would  take  up  the  whole 
time  of  a  resident  medical  officer. 

The  medical   officer  of  health   should  advise   the 


HOSPITAL  MANAGEMENT  I77 

Local  Authority  in  regard  to  the  general  manage- 
ment of  Isolation  Hospitals.  He  should  see  that  all 
necessary  precautions  are  carried  out  with  a  view  to 
prevent  the  spread  of  infection  either  in  or  from  the 
hospital.  No  patient  should  be  discharged  except 
by  his  orders.  He  should  frame  regulations  for 
the  admission  and  discharge  of  patients,  the  guid- 
ance of  nurses  and  other  officers,  the  admission  of 
visitors,  and  for  the  general  working  of  the  hospital. 
He  should  have  entire  control  under  the  Local  Authority 
over  all  measures  that  may  be  taken  for  the  protection 
of  the  patients  and  the  public. 

The  visiting  physicians,  on  the  other  hand,  should 
have  entire  control  over  the  cases  under  their  charge 
in  so  far  as  the  orderinof  of  suitable  diet  and  medicines 
or  other  means  of  treatment  are  concerned. 

"In  every  hospital  a  book  should  be  kept  contain- 
ing information  as  to  the  circumstances  of  patients 
admitted, — the  facts  to  be  recorded  in  it  being  quite 
distinct  from  those  relating  to  the  history,  symptoms, 
and  course  of  disease, — and  to  the  treatment  adopted. 
The  absence  of  such  an  '  admission  book '  has  been 
found,  during  the  course  of  this  inquiry,  to  have  caused 
considerable  Inconvenience  to  sanitary  authorities  and 
their  officers  when  desiring  to  collect  information  con- 
cerning the  usefulness  or  otherwise  of  their  hospital." 
Dr.  Thorne  Thorne  suggests  the  following  headings 
for  such  a  book,  and  states  that  for  some  hospitals  part 
of  the  information  would  be  unnecessary,  while  for 
others  additional  headings  might  be  required. 

N 


178 


PREVENTION  OF  EPIDEMICS 


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In  some  hospitals,  according  to  their  size  and 
requirements,  one,  two,  or  more  nurses  should  be 
permanently  employed,  while  in  others  this  would  not  be 
found  necessary.  When  a  nurse  is  not  permanently 
employed,  an  intelligent  woman  might  be  allowed  a 
small  remuneration  to  keep  the  hospital  fired  and 
aired,  and  always  in  readiness  for  the  reception  of 
patients.  Arrangements  might  be  made  for  her 
residence  in  the  administrative  building.  She  might, 
if  necessary,  attend  to  a  patient  until  the  arrival  of  a 
nurse,  If  such  an  emergency  occurred.  During  the 
time  patients  are  under  treatment  she  might  do  the 
cooking,  and  otherwise  render  assistance. 

In  some  cases  a  man  and  his  wife  might  live  rent 
free  in  the  administrative  building,  the  husband  being 
allowed  to  earn  his  living  otherwise,  when  the  hospital 
is  not  in  use,  but  to  act  as  ambulance  driver,  or  to 
render  such  assistance  as  might  be  found  necessary  at 
reasonable  wages,  when  the  hospital  was  occupied. 


Nl/RSES  179 

It  is  of  great  importance  that  provision  should  be 
made  whereby  the  services  of  one  or  two  nurses  might 
be  obtained  at  any  time  with  the  least  possible  delay. 
In  large  counties   a  permanent  staff  of  a  few  nurses 
might  be  always  engaged  in  one  hospital  or  another. 
It  might  suit  some  districts  or  counties  to  pay  a  retaining 
fee  to  a  nurse's  institute  in  one  of  the  large  towns  to 
secure  the  services  of  one  or  more  nurses  when  re- 
quired.     Ladies    in   several    parts    of    Scotland   have 
started    rural    nursing   associations  for  the  supply  of 
district  nurses.     One  of  these,  at  least,  has  in  contem- 
plation the  supply  of  nurses  to  Isolation  Hospitals  in  the 
district    when    necessary.       In    engaging    nurses    for 
infectious    disease,   it    is    generally  desirable   to  have 
them  protected  by  a  previous  attack.     In  the  case  of 
smallpox,   revaccination,    properly    done,    is    sufficient 
protection.      In  diphtheria  one  attack  does  not  protect 
a  person  from  the  disease.       Adults,  however,  are  not 
so  liable  to  suffer  as  young  persons,  and,  with  proper 
precaution,  the  danger  of  infection  is  not  so  great  as 
with  some  other  diseases. 

That  there  is  considerable  danger  of  infection  being 
conveyed  from  one  person  to  another  by  a  third  party 
may  be  seen  from  the  following  facts : — A  friend  of 
mine,  a  general  practitioner  in  a  rural  district,  informed 
me  that  one  day  he  had  in  the  morning  to  visit  a  person 
suffering  from  measles.  There  were  symptoms  of  lung 
complication,  and  he  had  to  make  a  minute  examination 
of  his  patient,  and  come  into  close  personal  contact 
with  him.     He  immediately  afterwards  drove  a  dis- 


i8o  PREVENTION  OF  EPIDEMICS 

tance  of  seven  miles,  and  when  passing  a  lonely  cottage 
by  the  roadside  was  called  in  to  see  another  case,  a 
child,  and  here  also  had  to  make  a  minute  examination 
of  his  patient.  Between  ten  and  eleven  days  after- 
wards, when  measles  had  time  to  incubate,  this  last  case 
was  taken  ill  with  that  disease.  The  case  was  isolated 
in  a  lonely  house  in  an  out-of-the-way  part  of  the  district, 
and  had  no  communication  with  any  infected  family. 
The  doctor  made  a  thorough  inquiry  and  had  to  come 
to  the  conclusion  that  he  was  the  carrier  of  the  infection 
himself. 

It  is  therefore  essential  that  every  care  should  be 
taken  to  prevent  an  Isolation  Hospital  from  becoming  a 
centre  from  which  diseases  may  spread.  For  this  pur- 
pose it  is  necessary  to  have  rules  for  the  guidance  of 
the  nurses  and  others.  In  towns  where  infectious 
hospitals  are  often  built  in  thickly  populated  localities, 
extreme  care  is  required.  In  the  North- Western  Dis- 
trict Hospital  of  the  Metropolitan  Asylums  Board,  Dr. 
Gayton  informs  me  that  no  one  is  permitted  to  pass 
the  gates  (nurses  or  others)  unless  furnished  with  a 
certificate  signed  by  the  bath  attendant  setting  forth 
that  she  "has  had  a  bath  and  changed  her  hospital 
uniform  for  her  private  clothing."  To  further  ensure 
the  rule  being  carried  out,  a  room  has  been  constructed 
furnished  with  lock-up  cupboards — one  appropriated 
to  each  member  of  the  staff — where  all  private  articles 
of  wearing  apparel  must  be  kept.  This  apartment 
being  close  to  the  bath-rooms,  the  plan  of  procedure  is 
rendered  very  simple,  though  doubtless  somewhat  irk- 


NUI^SES  i8i 

some,  and  is  as  follows  : — The  bath  being  taken,  and 
the  official  uniform  left  in  charge  of  the  attendant,  the 
nurse  passes  from  this  room  to  the  adjoining  one  con- 
tainingher out-door  clothing,  and, being  dressed, emerges 
from  a  door  at  the  other  end  into  the  grounds  of  the 
hospital.  The  order  of  things  being,  of  course,  re- 
versed upon  her  return  to  duty.     (Report,  18S4,  p.  7.) 

At  the  Belvidere  Hospital,  Glasgow,  this  is  not 
done,  and  Dr.  Russell  informed  me  that  he  was  not  able 
to  trace  infection  at  any  time  to  the  nurses.  The  Bel- 
videre Hospital  is,  however,  fairly  isolated.  Each 
ward  block  is  entirely  disconnected  from  the  rest  of 
the  building.  There  are  not  even  covered  corridors. 
The  nurses  are  often  in  the  open  air.  They  are  pro- 
vided with  overcoats,  and  when  going  off  duty  they 
simply  take  off  their  hospital  uniform  and  wash  them- 
selves. In  small  towns  and  rural  districts  this  would 
probably  be  found  quite  sufficient. 

"In  the  Blegdam  Hospital,  Copenhagen,  the 
central  portion  of  the  front  administration  block  con- 
tains two  bath-rooms  for  the  visiting  medical  staff 
Each  bath-room  has  on  each  side  a  dressing-room,  one 
communicating  with  the  entrance  hall,  the  other  with 
a  lobby  leading  out  to  the  wards.  The  medical  officer 
on  arriving  leaves  his  ordinary  clothes  in  the  front 
dressing-room,  and  passing  through  the  bath-room 
assumes  his  hospital  garments.  On  returning  he  re- 
verses the  process,  and  in  addition  takes  a  bath  before 
putting  on  his  ordinary  clothes."  ^ 

i  Burdett,  Hospitals  and  Asylums  of  the  World,  vol.  iv.  pp.  283,  284. 


1 82  PREVENTION  OF  EPIDEMICS 

Visitors  to  Isolation  Hospitals  may  also  convey 
infection.  The  following  are  the  rules  regulating  the 
visiting  of  patients  in  the  Hospitals  of  the  Metropolitan 
Asylums  District  Board  :  ^ — 

1.  The  visiting  of  patients  in  these  hospitals  is 
limited  to  the  nearest  relatives  and  intimate  friends  of 
patients  dangerously  ill.  One  visitor  will  be  allowed 
to  each  of  such  patients.  Such  visits  can  only  be  made 
with  the  permission  of  the  medical  superintendent,  and 
will  be  limited  in  duration  to  a  quarter  of  an  hour,  ex- 
cept in  very  urgent  cases,  when  two  visitors  will  be 
allowed,  and  the  duration  of  the  visits  may  be  extended. 

2.  Notice  will  be  sent  to  the  nearest  known  rela- 
tives or  intimate  friends  of  patients  dangerously  ill,  with 
an  intimation  that  they  may  be  visited.  Such  notice 
will  be  accompanied  by  a  copy  of  the  regulations  under 
which  visits  can  be  made. 

3.  A  list  of  patients  dangerously  ill  will  be  sent  daily 
at  one  o'clock  by  the  medical  superintendent  to  the 
gate  porter,  to  enable  him  to  answer  inquiries. 

4.  Visitors  are  warned  that  they  run  great  risk  in 
entering  the  hospitals.  No  one  should  attempt  to 
enter  the  wards  of  a  smallpox  hospital  without  having 
been  previously  properly  revaccinated,  and  if  he  lives 
in  a  house  where  smallpox  has  occurred,  he  is  urged  at 
once  to  apply  to  the  public  vaccinator  (whose  address 
can  be  obtained  from  any  of  the  parish  officers)  in 
order  that  the  remainder  of  the  occupiers  of  such  house 
may  be  vaccinated. 

1  Smallpox  and  Fever  Hospitals  Commission  Report,  jd.  380. 


VISITORS  183 


5.  Visitors  are  advised  [a]  not  to  enter  any  of  the 
wards  when  in  a  weak  state  of  health  or  in  an  exhausted 
condition.  (<5)  To  partake  of  food  before  entering  the 
hospital,  {c)  To  avoid  touching  the  patient  or  exposing 
themselves  to  his  breath  or  to  the  emanations  from  his 
skin,  {d)  To  sit  on  a  chair  at  the  bedside  at  some 
little  distance  from  the  patient,  and  not  to  handle  the 
bedclothes. 

6.  Visitors  will  be  required  to  wear  a  wrapper 
(which  will  be  provided  at  the  hospital)  to  cover  their 
dress  while  in  the  wards,  and  to  wash  their  hands  and 
face  with  carbolic  soap  and  water  before  leaving  the 
hospital,  or  to  use  some  other  mode  of  disinfection  at 
the  discretion  of  the  medical  superintendent. 

7.  Visitors  are  strongly  urged  not  to  enter  any 
omnibus,  tramcar,  or  any  other  public  conveyance 
immediately  after  leaving  the  hospital. 

On  the  admission  of  a  patient  to  any  of  the  hospitals 
of  the  Metropolitan  Asylums  District  Board,^  a  letter 
will  be  sent  to  the  nearest  known  relative  or  friend, 
setting  forth  the  state  of  the  patient.  Should  any 
serious  change  for  the  worse  take  place,  a  letter  will 
be  sent  daily  to  the  relative  or  friend,  stating  how  the 
patient  is  progressing,  which  letter  will  be  continued 
until  the  patient  is  in  such  a  condition  as  to  render 
further  communication  unnecessary.  But  should  the 
patient  become  dangerously  ill,  notice  will  be  sent  to 
the  nearest  known  relative  or  intimate  friend  that  the 
patient  may  be  visited,  and,  at  the  discretion  of  the 

1  Metropolitan  Asylums  District  Board  Regulations,  i8th  June  1S87. 


1 84  PREVENTION  OF  EPIDEMICS 

medical  superintendent,  arrangements  may  be  made 
for  the  conveyance  of  the  visitor  to  and  from  the 
hospital.  Inquiries  as  to  the  condition  of  the  patients 
must  be  made  in  writing  to  the  medical  superin- 
tendent, who  will  reply  by  return  of  post.  It  is  very 
undesirable  that  friends  of  patients  should  personally 
make  inquiries  at  the  hospital. 

In  the  Belvidere  Hospital,  Glasgow,  a  large  room 
is  provided  with  seats  near  the  entrance  gate.  Visitors 
enter  this  room  from  the  outside  at  a  stated  hour  every 
day.  At  a  considerable  height  above  the  floor  there 
are  openings  numbered  to  correspond  with  each  ward. 
The  nurse  of  each  ward  comes  to  this  opening  from 
the  outside,  and  gives  information  regarding  any 
patients  in  her  ward. 

The  appearance  of  the  building  and  the  manner  in 
which  the  hospital  and  grounds  are  kept  are  of  great 
importance  in  creating  a  kindly  feeling  towards  it  in 
the  neighbourhood.  In  many  places  very  little  atten- 
tion is  paid  to  this.  In  rural  districts  too  much  is  left 
to  nature.  The  purity  of  the  outside  air  will  not, 
however,  make  up  for  unhealthiness  caused  by  over- 
crowding or  damp  walls,  or  insufficient  means  for 
ventilation  or  want  of  cleanliness  inside  an  hospital, 
or  dirt  and  slovenliness  without. 

It  is  quite  as  necessary  to  provide  healthy,  attractive 
buildings  in  the  country  as  it  is  in  towns. 

Overcrowding,  poverty,  and  filth  will  act  as  a  nidus 
for  typhus  as  certain  in  a  lonely  cottage  exposed  to  the 
purifying  Atlantic  breeze  as  in  the  dirtiest  slums  of  a 


CLEANLINESS  185 

town.^  Typhoid  fever  ^  will  lurk  about  a  country  house 
of  defective  construction  with  the  same  certainty  as  in 
a  town  dwelling.  A  crust  ^  of  smallpox  will  retain  its 
infecting  qualities  for  years  while  lodging  in  the  walls 
of  a  country  house.  Defective  ventilation,  damp 
walls,  soil  saturated  with  organic  matter,  have  the  same 
evil  effect  in  town  and  country.  As  Sir  John  Simon 
stated,  "  that  which  makes  the  healthiest  house  makes 
the  healthiest  hospital  ;  the  same  fastidious  and  uni- 
versal cleanliness,  the  same  never-ceasing  vigilance 
against  the  thousand  forms  in  which  dirt  may  disguise 
itself  in  air  and  soil  and  water,  in  walls  and  floors  and 
ceiling,  in  dress  and  bedding  and  furniture,  in  pots  and 
pans  and  pails,  in  sinks  and  drains  and  dust  bins.  It 
is  the  same  principle  of  management,  but  with  immeas- 
urably greater  vigilance  and  skill,  for  the  establish- 
ment which  has  to  be  kept  in  such  exquisite  perfection 
of  cleanliness  is  an  establishment  which  never  rests 
from  fouling  itself,  nor  are  there  any  products  of  its 
foulness,  not  even  the  least  odourless  of  such  products, 
which  ought  not  to  be  regarded  as  a  poison."^ 

In  many  parts  of  England  much  attention  is  paid 
to  the  necessity  of  making  Isolation  Hospitals  attractive 
in  appearance  as  well  as  healthy  in  design,  construction, 
and  management. 

The  little  hospital  at  Ealing  is  one  example  of  this. 

1  Typhus  fever  is  frequently  met  with  in  lonely  cottages  in  Skye  and  other 
places  in  the  Highlands  of  Scotland. 

2  Cases  of  typhoid  in  country  houses  already  given. 

2  The  case  of  smallpox  recorded  by  Dr.  Carpenter  occurred  in  Mull. 
*  Report  of  Medical  OfScer  to  the  Privy  Council,  1863. 


1 86  PREVENTION  OF  EPIDEMICS 

Not  only  are  the  buildings  attractive  in  appearance 
and  well  kept,  but  the  grounds  around  them  are  beauti- 
fully laid  out,  planted  with  a  profusion  of  trees,  shrubs, 
and  flowers,  and  kept  in  perfect  order.  Even  the  name 
by  which  the  building  is  known,  as  I  have  endeavoured 
to  explain  in  the  preface,  is  of  importance  in  contri- 
buting to  the  success  of  the  institution. 

An  ambulance  carriage  or  carriages  should  be  pro- 
vided, according  to  the  requirements  of  the  district, 
for  the  conveyance  of  patients  to  Isolation  Hospitals. 
Such  an  ambulance  is  a  necessary  appendage  to  every 
Isolation  Hospital.  Persons  suffering  from  infectious 
diseases  are  seldom  able  to  walk  to  a  hospital,  and 
even  if  able,  it  is  very  undesirable  that  they  should  do 
so,  as  they  might  communicate  the  disease  to  such  as 
might  meet  them  on  the  way.  It  is  also  very  undesir- 
able that  persons  suffering  from  infectious  diseases 
should  be  carried  to  a  hospital  in  any  private  carriage, 
as  such  carriages  are  not  easily  disinfected. 

According  to  the  Public  Health  Acts,  persons 
suffering  from  infectious  diseases  are  prohibited  from 
exposing  themselves  either  on  streets,  roads,  or  public 
places,  or  to  travel  in  any  public  conveyance.  It  is, 
therefore,  absolutely  necessary  for  Local  Authorities 
to  provide  properly  constructed  ambulances  for  the 
conveyance  of  patients  to  their  hospitals.  An  ambul- 
ance carriage  should  be  so  constructed  as  to  enable  the 
patient,  if  necessary,  to  lie  down.  It  should  be  of 
sufficient  size  to  enable  a  nurse  to  accompany  the 
patient.      It  should  be  constructed  of  light  but  durable 


AMBULANCE   CARRIAGE  187 

material,  and  of  such  a  nature  as  to  prevent  the  absorp- 
tion of  infectious  organisms.  The  inside  should  be 
plainly  furnished,  so  as  to  facilitate  thorough  disin- 
fection each  time  the  carriage  is  used.  The  berth 
occupied  by  the  patient  should  be  a  combination  of  a 
bed  and  stretcher,  so  that  it  may  be  carried  if  necessary 
into  the  house  before  the  patient  is  disturbed,  and  into 
the  ward  where  he  is  to  be  isolated  and  put  to  bed. 

There  should  be  a  seat  for  the  nurse  inside  the 
carriage,  a  speaking  tube  to  communicate  with  the 
the  driver,  and  a  small  locker  in  which  stimulants  and 
restoratives  could  be  kept.  The  ambulance  should 
also  be  properly  ventilated,  and  provided  with  subdued 
light.  It  should  have  smooth  elastic  springs,  and  the 
wheels  should  be  provided  with  rubber  tyres.  It  is 
also  very  desirable  that  the  ambulance  in  country 
districts,  where  the  roads  are  narrow,  with  sharp  turns, 
should  be  so  constructed  as  to  suit  such  contingencies. 

Ambulance  carriages  of  the  above  description  are 
made  and  sold  at  reasonable  prices  by  different  firms 
in  this  country. 

The  success  of  Isolation  Hospitals  in  preventing  the 
spread  of  infectious  disease  depends  to  a  great  extent 
on  the  rapidity  with  which  patients  are  removed  from 
their  houses  after  the  disease  is  declared  to  be  infectious. 
For  this  purpose  an  ambulance  should  be  always  in 
readiness  to  start  within  the  shortest  possible  time. 
In  London  the  organisation  for  the  removal  of  patients 
is  carried  to  great  perfection.  Three  ambulance 
stations,   fully   equipped  with   horses,  drivers,  nurses, 


1 88  PREVENTION  OF  EPIDEMICS 

helpers,  telephone  clerk,  and  superintendent,  are  pro- 
vided by  the  Metropolitan  Asylums  Board.  Applica- 
tions for  admission  are  generally  made  by  patients  or 
Local  Authorities  to  the  central  office  of  the  Board. 
Within  three  minutes  of  a  summons  being  received 
at  the  ambulance  station  from  the  central  office  for  the 
removal  of  a  patient  the  ambulance  is  started  on  the 
journey. 

The  following  are  some  of  the  regulations  of  the 
Metropolitan  Asylums  Board  for  the  removal  of  persons 
suffering  from  infectious  diseases  : — 

(i)  Apply — On  Week  Days,  between  9  a.m.  and  8  p.m.,  to  the 
Chief  Offices  : — 

Postal  Address:  Norfolk   House,  Norfolk  Street,  Strand. 
Telegraphic  Address :  Asylums  Board,  London. 
Telephone  Number  :   2587. 

N.B. — Applications  in  the  latter  part  of  the  day  must  be  dis- 
patched in  time  to  reach  the  Offices  before  8  p.m. 
At  Night  between  8  p.m.  and  9  a.m.,  and  on  Sundays,  Christmas 
Day,  and  Good  Friday,  to  the  Ambulance  Stations  : — 

Eastern  Ambulance  Station,  Brooksby's  Walk,  Homerton,  N.E. 
South-Eastern  Ambulance  Station,  New  Cross  Road  (near  Old 

Kent  Road  Railway  Station),  S.E. 
Western  Ambulance  Station,  Seagrave  Road,  Fulham,  S.W, 

Removal  to  the  Boards  Hospitals 

[a)  Only  persons  suffering  from  Smallpox,  Fevers,  or  Diph- 
theria are  admitted  into  the  Board's  Hospitals. 

{b)  Every  application  must  state  the  name,  age,  and  full  address 
of  the  patient,  from  what  disease  suffering,  and  in  cases  of 
fever,  the  particular  kind  of  fever  ;  and  also  the  name  of  the 
person  making  the  application. 

{c)  Unless  a  Medical  Certificate  be  handed  to  the  Ambulance 
Nurse  the  patient  will  not  be  removed. 

{d)  Patients  should  leave  all  valuables,  money,  etc.,  and  all  out- 
side clothing  at  home,  should  wear  body  linen  only,  and  be 
wrapped  in  the  blankets  provided  for  the  purpose. 


AMBULANCE  STATION—REGULATIONS  189 

{e)  The  Ambulance  Nurse  will  leave,  at  the  house  from  which 
the  patient  is  removed,  a  notice  stating  the  hospital  to  which 
the  patient  is  to  be  taken,  and  a  copy  of  the  regulations  as 
to  visiting,  etc. 

Conveyafice  to  other  Places 

(a)  Persons  suffering  from  any  dangerous  Infectious  Disease 
may  be  conveyed  by  Ambulance  to  places  other 
THAN  the  Board's  Hospitals. 

JV.B. — Dangerous  Infectious  Diseases  include  the  follow- 
ing : — Smallpox,  Cholera,  Diphtheria,  Membranous  Croup, 
Erysipelas,  Scarlatina  or  Scarlet  Fever,  Typhus,  Typhoid, 
Enteric,  Relapsing,  Continued,  and  Puerperal  Fevers,  and 
Measles, 

(d)  Every  application  for  an  Ambulance  must  state  : — 
(i.)   Name,  sex,  and  age  of  patient, 
(ii.)  Description  of  disease,  and,  in  the  case  of  fever,  the 

particular  kind  of  fever, 
(iii.)  Full  address  from  which  the  patient  is  to  be  con- 
veyed, 
(iv.)  Full  address  to  which  the  patient  is  to  be  conveyed. 

(c)  The  patient  must   be  provided  with  a   Medical   Certificate  of 

the  nature  of  the  disease,  to  be  handed  to  the  driver  of  the 
Ambulance. 

(d)  The  charge  for  the   hire  of  the  Ambulance,  including  (when 

the  patient  is  over  ten  years  of  age)  the  services  of  a  male 
attendant,  is  5s.  This  amount  must  be  paid  to  the  driver, 
who  will  give  an  official  receipt  for  the  same. 

(e)  One   person   only   will   be  allowed   to   accompany   the  patient, 

and  such  person  may  be  conveyed  back  to  the  place  from 
which  the  patient  was  conveyed.  If  desired,  a  nurse  will  be 
supplied  at  an  additional  charge  of  2s.  6d.  for  her  services, 
(/)  The  Ambulances  may  be  sent  outside  the  Metropolitan  dis- 
trict only  by  special  sanction  of  the  Ambulance  Committee 
or  of  the  Clerk  to  the  Board,  and  in  such  cases  an  extra 
charge  will  be  made  of  is.  for  every  mile  outside  the  Metro- 
politan area. 

The  drivers  of  the  Board's  Ambulance  are  not  allowed  to  loiter 
on  their  journeys  or  to  stop  for  refreshments,  on  pain  of  instant  dis- 


I  go  PREVENTION  OF  EPIDEMICS 

missal.  It  is  particularly  requested  that  any  breach  of  this  regula- 
tion, or  any  neglect  or  incivility  on  the  part  of  the  drivers,  nurses, 
or  attendants  may  be  immediately  reported  to  the  undersigned. 

The  servants  of  the  Board  are  forbidden  to  accept  any  gratuities 
or  refreshments. 

By  Order. 

Dated  2 ^th  January  1892. 

N.B. — By  Section  70  of  the  '■'■  Public  Health  ( London)  Act,  1891," 
it  is  enacted  that — "  It  shall  not  be  lawful  for  any  owner  or 
"  driver  of  a  public  conveyatice  knowingly  to  cofivey,  or  for  any 
"  other  person  knowingly  to  place  in  any  public  conveyance,  a 
"  person  suffering  from  any  dangerous  infectious  disease,  or  for 
"  a  person  suffering  from  any  such  disease  to  e^iter  any  public 
"  conveyance,  and  if  he  does  so  he  shall  be  liable  to  a  fine  not 
'•'■  exceedinz  Ten  Pounds.  ..." 


(2)  Notice  of  Removal  of  Patient  to  Hospital 

Date  189 

To  the  Nearest   Relative  or   Friend   of  the  undermentioned   Sick 
Person. 
(Name  of  Patient) 
(Address) 
will   be  removed  to   the   North   Western   Hospital,    situate  at 
Haverstock  Hill,  Hampstead,  N.W.  (or  to  Hospital  Ships,  etc., 
according  to  circumstances). 

On  the  other  side  is  a  copy  of  the  Regulations  as  to  the  furnish- 
ing of  information  relative  to  the  condition  of  patients,  and  as  to  the 
visiting  of  patients  at  such  Hospital,  to  which  your  serious  attention 
is  requested. 

Important. — All  clothes  used  by  the  above  named  patient,  before 
his  (or  her)  removal  to  Hospital,  must  be  carefully  disinfected. 
To  ensure  this  being  done  apply  to  the  Local  Sanitary  Authority. 


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AMBULANCE   STATION— REGULATIONS  193 


(5)  Directions  to  Nurses 

To  take  charge  of  the  Ambulance,  giving  any  necessary  direc- 
tions to  the  driver. 

To  ride  inside  the  Ambulance  with  the  patient,  administering 
stimulant  if  necessary.  If  the  case  be  severe,  to  order  the  driver 
to  proceed  at  a  walking  pace. 

To  wear  the  uniform  provided  by  the  Managers.  To  see  that 
the  Ambulance  is  disinfected  at  Potter's  Ferry  after  delivering  up 
the  patient. 

To  see  that  no  stoppage  of  the  Ambulance  takes  place  on  the 
journey.  Any  breach  of  this  direction  will  lead  to  instant  dis- 
missal. 


(6)  Directions  to  Drivers 

The  driver  of  the  Ambulance,  on  receiving  his  instructions,  will 
go  to  the  address  given  him,  take  up  the  patient,  and  proceed  with 
due  care  and  diligence  to  ,  and  there  deliver 

up  the  patient  to  the  satisfaction  of  the  nurse ;  after  the  Ambulance 
has  been  disinfected  he  will  forthwith  return  to  the  Depot,  without 
stopping  or  calling  at  any  place  whatever,  on  pain  of  instant  dis- 
missal. 

The  police  have  been  instructed,  and  will  in  all  cases  report  to 
this  office  any  one  loitering  or  stopping  on  the  road,  except  for  the 
purpose  of  taking  up  or  discharging  the  patient. 


(7)  Instructions  to  Drivers  of  Ambulances 
Removal  of  Patients  to  other  places  than  the  Alanagers'  Hospitals 

The  patient  must  be  provided  with  a  medical  certificate  of  the 
nature  of  his  or  her  disease,  and  such  certificate  must  be  handed  to 
the  Ambulance  Driver,  and  be  by  him  delivered,  on  his  return  to  the 
Ambulance  Station,  to  the  Station  Superintendent. 

The  Driver  is  to  obtain  the  amount  charged  for  the  hire  of  the 
Ambulance  and  for  the  services  of  the  nurse  (when  provided),  to  give 
an  official  receipt  for  the  same,  and  to  hand  the  amount  over  to  the 
Station  Superintendent. 

O 


194  PREVENTION  OF  EPIDEMICS 

Drivers  are  not  allowed  to  loiter  on  their  journeys  or  to  stop 
for  refreshments,  on  pain  of  instant  dismissal. 

The  servants  of  the  Board  are  forbidden  to  accept  any  gratuities 
or  refreshments. 

(8)  When  a  driver  of  an  Ambulance  is  sent  to  remove  a  patient 
to  any  other  hospital  than  one  of  the  Managers'  hospitals,  he  is  to 
inquire,  before  the  patient  enters  the  Ambulance,  whether  arrange- 
ments have  been  made  for  the  reception  of  the  patient  at  the 
hospital  to  which  he  or  she  is  to  be  removed,  and  if  he  finds  that 
no  such  arrangements  have  been  made,  he  is  to  suggest  to  the 
patient's  friends  that,  as  there  may  not  be  room  at  the  hospital,  the 
Ambulance  should  be  again  applied  for  when  proper  arrangements 
shall  have  been  made;  but  if  the  removal  is  insisted  upon,  the  driver 
must  inform  the  patient  or  his  or  her  friends,  that  it  will  be  effected 
entirely  at  their  risk  and  cost. 

(9)  Ambulance  Stations 
Rules  and  Regulations  for  the  Guidance  of  the  Male  Staff 

The  whole  of  the  staff  must  be  up  each  morning  not  later  than 
5.45  A.M. ;  and  in  the  yard  ready  for  duty  at  6  o'clock. 

The  staff  will  take  their  meals  at  such  hours  as  may  be  directed 
by  the  Superintendent,  and  approved  by  the  Committee  of  Manage- 
ment. On  no  account  is  any  article  of  food  to  be  taken  from  the 
mess-room  to  the  dormitories. 

All  officers,  on  every  occasion  of  going  on  leave,  must  have  a 
bath,  and  substitute  their  own  clothing  for  their  uniform  before 
leaving  the  premises. 

All  officers  on  leave  are  to  return  punctually  to  the  Station.  If 
any  officer  is  late,  the  Superintendent  may  stop  his  leave  on  the 
next  occasion,  reporting  thereon  to  the  Committee  at  their  next 
meeting. 

In  the  case  of  an  officer  being  absent  without  leave,  a  deduc- 
tion will  be  made  from  his  wages,  and  the  matter  reported  to  the 
Committee. 

Any  officer,  in  case  of  illness,  shall  apply  to  the  Superintendent 
of  the  Station  for  an  order  to  see  the  Medical  Superintendent  of 
the  adjoining  Hospital  for  treatment. 

The  men's  leave  and  the  cleaning  of  the  dormitories  will  be 
regulated  in  detail  by  the  Superintendent. 


AMBULANCE   STATION— REGULATIONS  195 

No  man  is  permitted  to  sleep  in  the  dormitories  during  the 
day. 

No  smoking  is  allowed  in  any  other  part  of  the  Station  but  the 
mess-room. 

No  naked  lights  may  be  carried ;  and  when  matches  are  used, 
care  must  be  taken  that  they  are  not  thrown  down  whilst  alight. 

Any  officer  guilty  of  misconduct  or  insubordination  will  be 
liable  to  immediate  suspension  by  the  Superintendent,  who  will 
report  the  facts  of  such  suspension  to  the  Clerk  forthwith,  and  to 
the  Committee  at  their  next  meeting. 

The  coachman  next  for  duty  must  be  dressed  ready  to  go  out 
at  any  time  during  the  day. 

When  the  Superintendent  gives  the  signal  every  man  must  be  on 
the  alert,  and  must  assist  in  getting  the  Ambulance  out  as  speedily 
as  possible. 

The  coachmen  are  to  use  every  endeavour  to  find  the  patient. 
When  a  coachman  cannot  do  so,  he  should  go  to  the  Relieving 
Officer  of  the  district,  or  the  workhouse  of  the  parish. 

At  all  times  the  Ambulances  must  be  driven  with  due  care  and 
diligence. 

After  delivering  the  patient  and  nurse  the  driver  must  return 
forthwith  to  the  station  without  stopping  or  calling  at  any  place 
whatever,  on  pain  of  instant  dismissal. 

In  case  of  an  accident,  should  the  driver  be  unable  to  proceed 
upon  his  journey,  he  must  telegraph  from  the  nearest  telegraph 
office  the  particulars  of  the  accident  to  the  Superintendent. 

On  no  account  is  a  horse  to  be  left  alone  whilst  out  with  an 
Ambulance. 

(10)  Ambulance  Stations 
Rules  and  Regulations  for  the  Guidance  of  the  Female  Staff 

The  female  staff  must  be  up  each  morning  and  at  their  work  at 
hours  to  be  fixed  from  time  to  time  by  the  Superintendent. 

The  staff  will  take  their  meals  at  such  hours  as  may  be  fixed  by 
the  Superintendent,  and  approved  by  the  Committee  of  Manage- 
ment. On  no  account  is  any  article  of  food  to  be  taken  from  the 
mess-room  to  the  dormitories. 

All  officers  on  every  occasion  of  going  on  leave  must  have  a 
bath,  and  substitute  their  own  clothing  for  their  uniform  before 
leaving  the  premises. 


196 


PREVENTION  OF  EPIDEMICS 


All  officers  on  leave  are  to  return  punctually  to  the  Station.  If 
any  Officer  is  late,  the  Superintendent  may  stop  her  leave  on  the 
next  occasion,  reporting  thereon  to  the  Committee  at  their  next 
meeting. 

In  the  case  of  an  officer  being  absent  without  leave,  a  deduc- 
tion will  be  made  from  her  wages,  and  the  matter  reported  to  the 
Committee. 

Any  officer,  in  case  of  illness,  shall  apply  to  the  Superintendent 
of  the  Station  for  an  order  to  see  the  Medical  Superintendent  of 
the  adjoining  Hospital  for  treatment. 

The  women's  leave  and  the  cleaning  of  the  dormitories  will  be 
regulated  in  detail  by  the  housekeeper. 

Any  officer  guilty  of  misconduct  or  insubordination  will  be 
liable  to  immediate  suspension  by  the  Superintendent,  who  will 
report  the  facts  of  such  suspension  to  the  Clerk  forthwith,  and  to 
the  Committee  at  their  next  meeting. 

No  officer  is  permitted  to  sleep  in  the  dormitories  during  the 
day. 

Officers  must  retire  to  their  bedrooms  by  lo.o  p.m.,  and  all 
hghts  must  be  out  by  10.15  P-^^- 

No  naked  lights  may  be  carried ;  and,  when  matches  are  used, 
care  must  be  taken  that  they  are  not  thrown  down  whilst  alight. 


(11)  METROPOLITAN  ASYLUMS  BOARD 

EASTERN  DISTRICT  AMBULANCE  STATION 

Arrangements  for  working  and  tiecessary  requirements 
When  standing  in  the  stables  the  following  is  the  best  time  for 


feeding 

the  horses  : — 

I  St 

at 

5.15  (then  muck  out) 

2nd 

)) 

7-3° 

3rd 

11 

II. 0 

4th 

3J 

3-3° 

5th 

)3 

9.0  (Bed  down). 

Handful  of  hay 

in  between  to  keep  them  amused. 

Ambulances 

Each  Ambulance  (to  be  numbered  inside,  and  a  corresponding 
number  to  be  placed  over  the  door  or  shed)  to  be  fitted  with  shafts. 


A  MB  ULA  NCE   ST  A  TION—REGULA  TIONS 


197 


also  splinter  bar  and  pole  (splinter  bar  underside  of  futchells),  grating 
to  each  seat,  2  Stanhope  lamps  for  outside  (all  these  lamps  to  take 
same  sized  candles),  i  small  lamp  inside  to  hang  up,  i  fog  lamp  to 
hang  up  inside  also,  if  necessary  (both  these  lamps  are  oil  lamps). 

Stretcher  on  wheels,  with  hood  (Indiarubber  water-beds  used 
for  air  only),  Messrs.  Pocock  &  Brothers,  Indiarubber  bed,  pillow, 
and  seat,  ventilator  top  of  Ambulance,  outside  panels  in  wood, 
inside  lined  with  pitch  pine  (5  cut  stuff)  and  varnished. 

Spare  beds,  seats,  and  pillows  as  may  be  thought  necessary,  also 
a  few  brass  fittings  for  same ;  3  inflators ;  all  brass  fittings  to  be 
universal  for  the  inflators. 

Only  one  door  to  open  at  the  side  on  account  of  stretcher  ; 
door  to  open  at  back. 

One  cart  very  necessary,  in  case  of  an  accident  or  break  down, 
to  despatch  ropes  and  assistance. 

2  setters ;  2  shifting  spanners,  i  large,  i  small.  To  be  kept  in 
Superintendent's  office. 


24  spare  leather  window-blind  straps. 

24     ,,  ,,        door  straps. 

I  box  of  best  lamp  candles. 

Sperm  oil  for  lamps,  mixed  with  1/3 

paraffin  (fog  and  inside  lamps). 
Lamp  cotton,  say  25  yards.      Scissors 

for  trimming  lamps. 
Clips  and  bolts  of  different  sizes,  Roller 
.    bolts. 


I  20-round  ladder. 

24  bone  whistles. 

24  ambulance  door  keys. 

One  small  and  one  large  brand  iron, 

Initials  of  Station. 
I  bottle  jack  to  lift  two  tons. 
I  each  axe  and  saw. 
20  Indiarubber  mats  for  inside,  2  ft. 

+  I  ft.  6  in.,  Initials  of  Station. 


Harness,  etc.,  say  for  12  Horses 


6  sets  pair  horse  harness,  brass  mounted 
all  over.      Blinkers  and  hip  straps 
marked  M.A.B. 
12  pair  pole  straps. 
12  sets  single  harness,  brass  mounted 

all  over.     Marked  as  above. 
24  head  stalls,  2  hemp  reins  and  2  logs 
to  each.      24  hemp  reins,    12    logs 
(stock). 
12  driver's  whips. 
12  loin  leathers  and  straps. 
12  dandy  brushes. 

6  each,  hard  and  soft  compo.  brushes. 
6  oil  brushes. 
6  body     ,, 
12  water    ,, 


12  spoke  brushes. 

6  sets  shoe  brushes. 
12  curry  combs. 
12  horn  mane  combs. 
12  bath  sponges. 
24  carriage    ,, 
24  washing    ,, 

24  chamois  leathers  for  washing. 
24       „  „       for  polishing. 

6  stable  forks. 

6  sieves. 
Disinfecting  lamps  and  carbon. 
,,  powder. 

I  tape  and  2-foot  rule. 
Paints,  brushes,  varnishes,  oils,  white 
lead,  soft  soap,  lamp  black,  silver  sand. 


198 


PREVENTION  OF  EPIDEMICS 


2  half-peck  measures. 
24  whip  sockets. 

6  doz.  of  Harris's  harness  composition. 

3  doz.   of  Harris's  harness  polisliing 

paste. 
6  horse  scrapers. 
24     ,,      collars,  from  21  in.  to  22^  in. 
6    pairs    leather    washing    leggings, 
copper  riveted. 
24  mops  and  handles. 

3  pairs  knee  pads. 
12  horse  rugs  and  rollers. 
6  pairs  leather  collar  pads. 
6     ,,  ,,        horse  boots. 

12    ,,      Indiarubber       ,, 
3  posting  saddles,  girths,  cruppers,  etc. 
Smith's  tools,  iron,  steel,  timber,  box- 
ing   machine,   washer    cutter,   vice, 
anvil,  wheel  plate,  bender,  drilling 
machine,  grindstone. 


1 2  split  rings  to  fix  on  harness  for  tandem. 
Wheelwright's  materials. 

3  bridles,  riding  reins,  bits,  curbs. 

3  collars,  hames  &  tugs  &  hame  straps. 

3  posting  traces  with  brass  coach  eyes. 

6  sets  woollen  bands,  for  horses'  legs. 

6  pairs  galvanised  pillar  chains. 
12  nose  bags. 
12  wooden  pails  for  stable. 

2  doz.  galvanised  pails,  13  in.  x  13  in. 
24  bass  brooms  and  handles. 

2  clipping  combs  and  scissors. 

2  stable  barrows. 

6  shovels. 

6  stable  baskets  or  dung  skips. 

6  feeding  baskets. 
Corn  bin. 
Clark's   patent   clipping  and  singeing 

machine. 
50  feet  Indiarubber  gas  tubing. 


In  harness-room,  brackets  must  be  fixed  for  hanging  up  harness, 
saddles,  etc.,  and  gas  stove  for  winter. 

Recommended  that  gas  lights,  in  connection  with  the  Station 
in  the  stable  and  yard,  be  regulated  from  one  tap. 

1 2  pairs  clogs  with  iron  tips.  1 2  pairs  driver's  gloves  (double 
hand  parts). 

Office  :  commencing  from  the  Telephone 

Memo. — In  all  forms  of  printing  see  to  alteration  of  the  name  of 

Station,  etc. 


I  cash  safe. 

I  sq.   table,    i   ft.   6  in.  x  i   ft.   4  in., 

with  drawers  for  telephone  forms. 
1  parchment  slate  for  telephone  clerk. 
Form    I, — 1000    telephone    message 

forms  (qy.  in  black  and  red). 
Form  2. — 6  driver's  and  nurse's  note 

order  book  (qy.  in  black  and  red). 
I   large  slate,    i   ft.   6  in.   long.,  i  ft. 

wide,  scratched  in  to  correspond  with 

removal  book. 
I   particulars  of  removal  book.      (No. 

62,506.) 
Form  3. — 700  daily  return  forms. 

M     4-— 300  weekly     ,,        ,, 

,,      5. — 100  monthly  ,,        ,, 

,,     6.  — 100  monthly  abstract  forms. 


Form  7. — 1 000  removal  forms  to  clerks 

to  guardians. 
,,     8.  — 100  envelopes  (each  parish) 

printed  addresses  to  do.  do. 

,,     9. — 250    tradesmen's     account 

forms  (3  pages). 

,,    10. — 500  tradesmens'  circulars. 

,,    II. — Rules  and  re-^  „   ,    , 

j   lo  be  framed, 

gulations  to  drivers    I  glazed, &  hung 
,,    12. — Rules      and  j  on  the  walls  of 
directions  to  nurses  J  ^^he  mess  room. 
,,    13 — General  orders. 
500  returns  from  the  opening  of  station. 
I  Stanford's  library  map  of  London,  in 

24  sheets,  6  in.  scale,  mounted. 
I  London  Post  Office  Directory. 
I  Suburban  Directory. 


AMBULANCE   STATION— REGU LA  TIONS 


199 


I  Local  Government  Directory. 

I   book  of  regulations,  and    standing 

orders  of  the  Managers. 
I  office  desk. 
I      ,,      slope. 

1  office  chair. 

Stationery  of  all  descriptions  necessary, 
pens,  holders ;  black,  blue,  red,  and 
slate  pencils  (Faber's) ;  Indiarubber, 
2  rulers,  bottle  of  gum,  gum  bottle 
and  brush,  letter  scales,  clock  for 
office,  2  basket  trays,  2  double  ink- 
stands, 2  waste  paper  baskets,  6 
glass  paper  weights. 

2  books  indiced  throughout  (i   ruled 

with  money  columns). 
I  wages'  book,  ruled  wide  for  receipt 

stamps. 
I  petty  cash  book. 
I  Register  of  officers'  book. 
I  order  check  book. 
I  receipt  book  (numbered  i  to   100). 

No.  62,206. 

Memo. — All  entries  at  this  Station 
All  entries         ,,  ,, 


I  estimate  book.      No.  61,829. 

I  report  book. 

I  gate  book.      No.  6189. 

I  copying  book. 

I         ,,        press,  with  damping  brush 

and  water  well. 
I  blotting  pad. 

Half  ream  white  and  red  blotting  paper. 
I  Lett's  Diary.     No.  44. 
I  store's  account  book.      No.  63,764 

—  15/9/83- 

I  inventory  book. 

I  linen  account  book.       No.   63,763 

—  14/9/83- 
I  day  book. 

I  summary  of  day  book 
I  postage  book. 
I  stamp  for  marking  linen. 
I  brand  for  marking  utensils. 
Marking  ink. 
Lists  of  clothing  forms. 
I   large  book,  indiced  for  instructions 
from  Norfolk  St.,  paged  throughout. 

for  Smallpox  are  made  in  black. 
Fever  „  ,,        red. 


Men's  Mess-room 
If  possible  the  map  out  of  the  London  Directory  should  be 
mounted  on  rollers,  sized  and  varnished,  then  hung  up  in  the  mess- 
room. 

The  rules  and  regulations  should  also  be  framed,  glazed,  and 
hung  up  on  the  walls  of  the  mess-room. 
Coffee       at        7.0  am.. 
Breakfast  „         8.0    „ 
Lunch        ,,    10.30    „ 
Dinner       ,,    12.30    „ 
Tea  „      4.30    „ 

Supper      „      8.30    ,, 

To  bed  sharp  at  10.15,  unless  some  of  the  Ambulances  are  out, 
when  one  horsekeeper  and  the  driver  next  for  duty  will  sit  up,  the 
remainder  to  be  compelled  to  go  to  bed. 

Drivers 
To  commence  at  six  o'clock,   start  cleaning  harness,  one  ap- 
pointed in   rotation  to  wash,  until  some  is  washed  and  dried,  the 


allowed  10  minutes 

„        60        „ 
n         30         ;> 

30        »       . 


If  business 
permits. 


PREVENTION  OF  EPIDEMICS 


others  get  on  with  the  bridles  (bits  to  be  put  in  the  pickle  tub) ; 
as  the  harness  is  washed  it  is  passed  on  to  others  to  compo.,  while 
some  clean  the  brass  mountings,  etc.  ;  when  finished  to  be  hung  up 
in  the  harness-room ;  one  man  to  be  appointed  to  see  the  double 
harness  is  paired  properly  and  ready  for  use ;  any  wanting  repairs 
to  be  reported  to  the  Superintendent. 

See  occasionally  to  all  leading  and  spare  harness,  or  it  will  get 
out  of  order. 

When  the  harness  is  done  and  put  away,  clean  gas  lamps  in 
yard,  harness-room,  lavatory,  etc.,  and  do  such  sundry  jobs  as  may 
be  necessary. 

At  this  Station  the  driver  first  on  turn  reports  himself  ready  by 
10.30  a.m.  to  Superintendent;  in  all  cases,  soon  as  the  work  is 
done,  the  men  should  clean  themselves  and  be  prepared  for  a  call. 

Each  driver  must  have  a  place  for  his  whip,  waterproof,  knee- 
apron,  etc.,  so  that  they  can  be  found  when  wanted ;  when  he 
receives  a  call  he  puts  his  things  on  the  box  of  the  Ambulance, 
goes  to  the  office  for  his  written  orders ;  soon  as  the  horse  or 
horses  are  put  to,  he  will  get  on  the  box  (in  all  cases  picking 
up  his  reins  before  doing  so) ;  when  the  nurse  is  inside,  she 
having  received  her  note  also,  the  Superintendent  will  tell  him  to 
proceed  on  his  journey. 

Each  driver,  when  engaged,  to  find  one  whip.  Each  driver,  in 
fact  all  the  men,  should  be  provided  with  some  canvas  for  aprons, 
to  wear  while  cleaning  the  harness,  etc. 


Uniforms 

2  suits  white  duck  overalls  (jacket  and  i  pair  driving  gloves,  with  double  hand 

trousers  only.  parts. 

I  tweed  suit.  i  waterproof  knee  apron. 

I   livery  suit   (M.A.B.)    on" 

collar,      metal      buttons, 

coat,  sleeve  w^aistcoat,  and 

trousers. 
I  livery  great  coat,  M.A.B. 

on  collar 


seams  except 
trousers. 


I  pair  clogs. 
I  bone  whistle. 
White  cord      j  ^i-^ip_      Driver  finds  one  also. 

r  seams  excent 

I  Ambulance  key. 

I      pair     waterproof    leggings     (dark 
tweed). 
2  caps  and  oilskin  covers  (the  latter  to         Weekly,     i     box,     Bryant    &    May's 

cover  neck).  matches,  to  each  of  the  male  staff. 

I  waterproof  driving  coat  (white).  Comb  and  hair  brush. 

Memo, — Every  male  engaged   should  be  able  to  drive  if  neces- 
sary, and  at  least  two  of  staff  should  be  able  to  ride  horseback. 


AMBULANCE   STATION—REGULATIONS  201 

HORSEKEEPERS 

(To  get  up  at  5.15  o'clock,  and  feed  his  horses,  etc.) 

I   worsted  cord  suit.  (Sleeve  waistcoat     i  pair  driving  gloves, 
and  trousers.)  i     ,,     clogs. 

1  tweed  suit.  i  bone  whistle. 

2  caps  and  covers.  i  Ambulance  key. 

I  livery  small  coat.  i  waterproof  driving  coat. 

I  livery  great  coat.  i  ,,  knee  apron. 

I  pair  waterprof  leggings  (dark  tweed). 

Washer  and  Harness  Cleaner,  same  Clothing  as  Iforsekeepers. 

Messman  and  Driver,   Male  Attendant  and  Lamp 
Cleaner 

Two  suits  of  tweed.  Two  caps  and  covers.  One  hvery  small 
coat.  And  the  remainder  of  the  articles  mentioned  after  the  livery 
small  coat  above. 

The  Washer 

To  be  at  work  at  5.30.  Leather  leggings  for  self  and  another 
provided,  also  clogs.  Lamps  to  be  taken  off  and  put  in  a  place 
appointed  ready  for  cleaning.  Commence  washing  Ambulances 
that  have  been  used  the  day  previous,  under  cover  if  wet  or  dark, 
on  the  outside  wash,  weather  permitting ;  if  in  washing  he  sees  any- 
thing displaced  or  broken,  to  report  same  to  Superintendent.  At 
6  o'clock  when  the  drivers  commence,  one,  who  has  been  previously 
told  off  (in  rotation)  comes  and  assists  ;  after  all  is  washed,  they 
must  be  leathered  off;  inside  sponged  and  dried,  air  beds,  pillows, 
and  seats  blown  up,  brass  work,  door  and  back  locks  cleaned, 
transomes  oiled,  and  the  Ambulances  .put  back  in  their  proper 
places,  which  are  supposed  to  be  numbered  the  same  as  the 
Ambulances  ;  see  his  lamps  trimmed  and  .bottom  piece  locked 
always  before  the  Ambulance  goes  out.  If  any  sign  of  fog,  see  a 
fog  lamp  is  placed  inside,  in  the  place  appointed  and  fastened ;  see 
that  splinter  bar,  pole,  and  pole  straps  are  in  their  places  behind 
each  single,  and  the  shafts  behind  each  pair,  properly  numbered 
same  as  Ambulance,  so  that  they  may  be  ready  at  a  moment's 
notice,  if  orders  are  given,  to  change  a  single  to  a  pair,  or  the 
reverse. 

The  bolts  on  both  singles  and  pairs  for  attaching  splinter  bar 


PREVENTION  OF  EPIDEMICS 


or  shafts  must  have  the  nuts  run  off  occasionally,  or  they  will  get 
set,  and,  when  wanted  to  change,  be  difficult  to  move. 

When  the  Ambulance  returns  from  a  journey,  to  wash  the  same 
decently;  at  any  rate,  to  sponge  the  panels,  and  leather  off;  see  to 
inside — that  bed,  pillow,  and  seat  is  blown  up,  and  everything 
made  decent  for  use  again  that  day  if  needed. 

To  be  prepared  (when  drivers  are  all  out)  to  go  with  an 
Ambulance,  if  ordered  to  do  so  by  Superintendent. 

Nurses 

The  nurses'  breakfast  at  .  .  .  8.0 

Dinner  at         .  .  .  12.30 

Tea  at         .          .          .          4- 30 
Supper  at         .  .  .  8.30 

And,  unless  out  in  an  Ambulance,  to  bed  at  10.15  sharp. 
The  nurse  first  on  turn  to  be  ready  when  she  comes  down  to 
breakfast;  all  should  be  ready  by  9.30,  having  previously  made 
their  beds,  emptied  slops,  dusted  room ;  it  being  understood  they 
keep  their  own  sleeping- room  clean,  except  scrub  the  floor  and 
clean  the  windows. 

The  housemaid  brings  the  nurses'  meals,  and  puts  them  on  a 
table  outside  their  mess-room  door,  the  nurses  take  it  from  there  ; 
after  they  have  had  their  dinner,  the  things  are  placed  on  the  table 
outside  by  the  nurses  for  the  maid  to  take  away. 

The  Superintendent's  wife,  as  housekeeper,  will  find  ample 
employment  in  seeing  the  house  is  kept  clean,  cooking  done 
properly,  that  no  waste  occurs,  that  the  nurses  do  not  go  to  their 
dormitories  to  sleep  in  the  day-time,  take  charge  of  the  linen,  mark 
and  repair  same,  take  account  of  and  send  soiled  linen  to  the 
laundry,  checking  and  seeing  to  the  airing  of  same  on  its  return, 
and  the  general  duties  appertaining  to  a  housekeeper. 

Superintendent 
Memos. 
To  study  the  map,  principally  the  district  he  will  have  to  work, 
to  be  enabled  to  instruct  the  drivers  where  they  have  to  pick  up. 

To  make  himself  acquainted  with  the  names  of  the  Relieving 
Officers,  so  that  by  reference  to  the  Local  Government  Directory 
he  will  see  from  what  parish  the  patient  comes,  in  case  the  informa- 
tion is  not  sent  him  by  telephone. 

On  receipt  of  telephone  message,  the  Superintendent  blows  on 


AMBULANCE   STATION— REGULATIONS  203 

his  whistle  twice  distinctly,  that  being  the  signal  for  the  head  horse- 
keeper,  the  Superintendent  instructs  him  thus  : — 

-p.     ,  r  F.  a  pair  1     That  is,  a  pair  of  horses  and  a  Fever  Ambulance. 

\  F.  single  J  ,,  Fever  Ambulance,  with  one  horse, 

or 
9\r  AT  T  vcy-^  /  Small,  a  pair  1  That  is,  a  pair  of  horses  and  a  Smallpox  Ambulance. 

\  Small,  single  J         ,,         Smallpox  Ambulance,  with  one  horse. 

Everyone  at  the  Station  being  on  the  alert  when  the  Superintendent 
whistles  tw^ice  : — The  washer  brings  out  an  Ambulance  to  the  place 
appointed  for  putting  the  horses  to ;  the  horsekeepers  put  the  harness 
on  the  horses,  everyone  assisting  to  do  what  they  can  (if  at  night- 
time, one  lights  the  outside  lamps,  another  the  inside  one,  etc.) ; 
no  excuse  from  this,  no  waiting  to  finish  dinner,  the  Ambulance 
is  to  be  sent  out  with  all  due  speed.  Three  calls  on  the  whistle 
will  have  warned  the  nurse,  who  is  supposed  to  be  ready  waiting. 

While  the  horses  are  being  put  to,  the  Superintendent  makes 
out  the  driver's  and  nurse's  notes,  on  which  he  has  written  the 
particulars  received  by  telephone. 

The  drivers  are  to  understand  they  must  use  every  endeavour 
to  find  the  patient ;  sometimes  the  number  may  be  wrong,  or  the 
street  not  spelt  correctly ;  if  he  cannot  do  so,  he  should  go  to  the 
Relieving  Officer  of  the  district,  or  the  workhouse  of  the  parish ;  he 
should  perfectly  understand,  if  he  came  back  to  the  Station  without 
removing  the  case,  another  horse  would  be  put  to  at  once  and  he 
would  be  sent  out  again,  unless  the  Superintendent  thought  other- 
wise. Every  effort  should  be  made  to  get  to  the  patient  as  soon  as 
possible,  and  deliver  the  case  at  the  Hospital  with  care. 

The  men's  leave  and  cleaning  the  dormitories  would  be  for  the 
Superintendent  to  consider  in  detail. 

It  should  be  a  strict  rule  that  neither  men  nor  nurses  be  permitted 
to  go  to  their  dormitories  to  sleep  during  the  day. 

It  is  indispensable  the  whole  of  the  male  staff  be  able  to  read 
and  write  legibly. 

No  smoking  permitted  while  at  work. 

All  clothing  and  utensils,  before  being  served  out,  to  be  branded 
with  initials  of  station. 


CHAPTER    IX 

Private  Sanitary  Aid  Associations 

Private  associations  have  been  found  of  much  ser- 
vice in  assisting  Local  Authorities  and  their  officials 
in  carrying  out  the  measures  necessary  to  prevent  the 
spread  of  infectious  disease.  As  long  as  the  behaviour 
of  infectious  diseases  is  imperfectly  understood,  or  the 
importance  of  taking  measures  to  prevent  them  is  not 
fully  appreciated,  so  long  will  such  associations  be 
found  useful.  At  present  they  are  of  importance 
in  bringing  the  matter  before  the  public.  But  when 
the  importance  of  preventing  disease  is  properly 
understood  and  appreciated,  private  associations  for 
this  purpose  will  not  be  required  any  more  than  such 
assistance  Is  now  necessary  for  the  suppression  of 
crime,  or  for  the  collection  of  the  Inland  Revenue. 

Mrs.  Francis  Johnstone,^  the  manager  of  the 
Sanitary  Aid  Association  at  Hastings,  stated  in  her 
evidence  before  the  Smallpox  and  Fever  Hospitals 
Commission,  that  "the  function  of  that  Association  is 
to  supplement  the  resources  of  the  medical  officers   of 

1  Fever  and  Smallpox  Hospitals  Commission,  Minutes  of  Evidence,  pp.  209, 


HASTINGS  ASSOCIATION  205 

health.       The    medical    officers    of    health    can    give 
orders,  but  they  cannot  relieve,  and  there  is  no  woman 
teacher  ;  they  can  give  orders,  but  not  detailed  instruc- 
tions.    The  inspectors  are  supposed  to  give  instruc- 
tions, and  to  a  certain  extent  they  do.      Sometimes, 
indeed,  the  inspectors  are  very  vigilant  and  good,  but 
as  a  rule  you  find  that  the  man  has  given  orders  in 
general  terms,   which,   until  our  woman    teacher   has 
explained    by   giving    detailed    instructions,    are    not 
thoroughly  understood."    The  Association  usually  gets 
information  from  district  visitors  in  regard  to  houses 
where    infectious    disease     prevailed.        The    clergy, 
with  their  whole  staff  of  teachers,  paid   and   unpaid, 
and  their  lay  helpers,  are  the  great  agency  for  infor- 
mation.    When  the  teacher  of  the  Association  visits 
the  mother  of  a  sick  child,  if  the  case  is  to  remain  at 
home,  she  "  teaches  the  mother  the  practice  of  disin- 
fection at  every  point,  so  that  from  the  moment  of  the 
child  being  isolated  in  a  separate  room,  nothing  that 
has    not    been    disinfected    leaves    the    room.       The 
teacher  continues  to  visit  the  case  during  a  period  of 
eight    weeks ;    no    matter    how    soon    the    child    may 
recover,  so  far  as  being  well,  during  eight  weeks  our 
care  continues."     "  If  the  case  is  removed  to  the  hos- 
pital we  ensure    disinfection.       As   I   have   said,    fre- 
quently it  is  all  done  rightly  without  us,  but  sometimes 
it  is  not.     We   complete  those  performances  as   they 
may  need  completion,  and  if  the  child  comes  out  of 
the  hospital  sooner  than  we  can  venture  to  let  it  go 
back  to  school,  we  attend  to  that." 


2o6  PREVENTION  OF  EPIDEMICS 


In  the  case  of  the  poor  certain  relief  is  given  if 
the  orders  of  the  medical  officer  of  health  are  really- 
carried  out.  "  The  motive  power  is  the  conditional 
relief;  the  relief  that  might  be  given,  if  no  respect  is 
paid  to  the  fulfilment  of  instructions,  is  stopped.  That 
is  why  we  take  it  off  the  Church  alms'  fund ;  the 
clergy  support  us,  and  we  take  all  those  cases  entirely 
off  their  hands." 

The  average  expenditure  for  the  protection  of  all 
the  people  [over  45,000]  is  ^100  a  year.  We  have 
only  one  salaried  person  in  the  society,  and  that  is  the 
teacher,  who  has  a  salary  of  £AfO  a  year.  The  re- 
maining £60  does  for  relief  of  all  kinds,  printing,  and 
disinfectants  sometimes,  as  well  as  other  expenses. 

This  Association,  according  to  Mrs.  Johnstone,  has 
been  successful  on  many  occasions  in  preventing  cases 
of  infectious  disease  from  spreading,  and  of  great  ser- 
vice in  supplementing  the  resources  of  the  medical 
officers  of  health.  The  following  are  some  of  the 
rules  of  the  Association  : — 


RULES  OF  THE  SANITARY  AID  ASSOCIATION 
AT  HASTINGS  1 

For  Boys'  Schools 

Scarlet  Fever 

It  is  quite  possible  to  check  scarlet  fever  if  proper  means  be 
taken  to  destroy  the  emanations  of  the  sick,  so  that  they  shall  not 
infect  the  healthy.  For  this  purpose  the  following  recommendations 
have  been  compiled  from  the  best  authorities  on  the  subject,  by  the 

^  Appendix   G  to   Smallpox  and  Fever  Hospitals   Commission,   Minutes   of 
Evidence,  pp.  339,  340,  341. 


REG  ULA  TIONS  207 


direction  of  the  Committee  of  the  Local  Board  of  Health  for  the 
district  of  the  city  and  county  of  Bristol,  and,  with  a  few  small  but 
very  important  additions  or  modifications,  are  adopted  by  the 
Hastings  and  St.  Leonards  Sanitary  Aid  Association  : — 

1.  If  a  case  of  scarlatina,  or  scarlet  fever,  or  bad  sore  throat, 
appear  in  your  house,  apply  immediately  to  a  medical  man,  and 
send  information  of  it  to  the  medical  officer  of  health,  and  to  the 
sanitary  aid  manager. 

2.  If  possible,  separate  the  patient  immediately  from  the  rest  of 
the  inmates.  A  room  at  the  top  of  the  house  is,  as  a  rule,  the  best 
sick-room. 

3.  Let  the  room  in  which  the  patient  hes  be  stripped  of  all 
carpets  and  curtains. 

4.  Let  all  the  discharges,  of  whatever  kind,  be  received  on  their 
very  issue  from  the  body  into  a  disinfectant,  such  as  Calvert's 
powder,  chloride  of  lime,  carbolic  acid,  or  Condy's  fluid,  and  con- 
tinue this  from  the  first  discovery,  or  even  suspicion,  of  scarlet 
fever  until  eight  weeks  from  that  date,  no  matter  how  much  sooner 
the  patient  may  appear  perfectly  well,  and  his  skin  quite  free  from 
any  remainder  of  peeling. 

5.  Let  small  pieces  of  rag  be  used  instead  of  pocket  handker- 
chiefs for  wiping  the  mouth  and  nose ;  each  piece  after  being  once 
used  should  be  immediately  burnt. 

6.  About  the  fourth  day  of  the  eruption  let  the  surface  of  the 
body  be  well  rubbed  with  camphorated  oil  daily,  the  oiling  to  be 
continued  until  the  patient  is  able  to  take  a  warm  bath,  in  which 
the  whole  skin  should  be  well  scrubbed  with  disinfecting  carbolic 
acid  soap. 

N.B. — In  no  case  must  the  sanitary  aid  visitor  order  oiling  or 
bath  without  consulting  the  medical  attendant  of  the  case ;  with  his 
permission  the  bath,  including  washing  the  head,  should  be  used 
twice  or  thrice  a  week  to  the  end  of  the  eighth  week. 

7.  The  patient  may,  if  a  clean  case,  in  clean  clothes  re-enter  the 
family  after  five  weeks  from  first  appearance  of  rash,  but  he  must 
not  kiss  any  one,  and  must  still  sleep  apart. 

8.  A  large  vessel,  containing  Condy's  fluid  in  the  proportion  of 
one  ounce  to  every  gallon  of  water,  should  be  kept  in  the  room. 
All  bed  and  body  linen,  on  its  removal  from  the  person  of  the 
patient,  to  be  immediately  placed  therein. 

9.  In  case  of  death,  the  corpse  should  be  smothered  with  car- 
bolic powder,  and  speedily  buried. 


PREVENTION  OF  EPIDEMICS 


10.  No  child  having  had  the  scarlet  fever  should  be  allowed  to 
re-enter  a  school  without  a  certificate  from  the  medical  officer  of 
health  stating  that  he  can  do  so  without  risk  to  others,  and  this 
certificate  must  not  be  asked  for  until  the  eighth  week  is  past,  and 
rule  1 1  completely  carried  out. 

11.  On  the  recovery  or  removal  of  a  patient,  all  floors,  walls,  and 
ceilings  should  be  fumigated,  scraped,  and  cleaned.  For  fumigating 
infected  rooms  and  their  contents,  nothing  is  better  than  sulphur. 
A  quarter  of  a  pound  of  brimstone,  broken  into  small  pieces,  should 
be  put  into  an  iron  dish  (or  the  hd  of  an  iron  saucepan  turned  up- 
side down),  supported  by  a  pair  of  tongs  over  a  bucket  of  water. 
The  chimney  and  other  openings  are  then  closed  with  paper  pasted 
on,  and  a  shovelful  of  live  coals  is  put  on  the  brimstone.  The  door 
is  then  quickly  shut,  the  crevices  covered  with  paper  and  paste,  and 
the  room  kept  closed  for  five  or  six  hours.  After  this  a  thorough 
cleansing  should  be  effected,  everything  washable  should  be  washed^ 
and  all  other  things  be  cleansed  by  proper  means. 

N.B. — There  is  an  important  distinction  to  be  observed  between 
a  clean  and  a  foul  case  of  any  fever.  A  clean  case  is  one  unattended 
by  any  description  of  involuntary  discharge.  A  foul  case  is  the  re- 
verse of  this.  In  a  foul  case  no  half  quarantine,  such  as  is  indicated 
in  Rule  7,  can  possibly  be  allowed  ;  for  instance,  an  infant  too  young 
to  exercise  self-control  as  to  the  ordinary  discharges,  must  remain  in 
strict  isolation  during  eight  full  weeks,  and  any  subject  thus  affected 
in  respect  of  any  discharge  whatever,  must  be  similarly  treated  while 
so  affected. 

The  before  mentioned  rules  apply  to  cases  not  constitutionally 
diseased.  A  case  with  running  sores  of  any  kind  must  be  entirely 
isolated  twelve  weeks,  or  there  can  be  no  security  against  the 
spread  of  the  disease. 

Daily  fumigation  of  the  sick-room,  and  of  the  house  in  which  it 
exists,  may  very  beneficially  be  performed  with  sticks  with  the  bark 
on,  sold  for  lighting  fires,  or  with  chips  dipped  in  tar,  when  live 
sticks  cannot  be  procured. 

A  person  nursing  a  fever  case,  who  has  never  had  the  fever, 
should  never  swallow  while  changing  soiled  clothing  or  attending  to 
discharges,  but  should  cleanse  nose  and  mouth  and  throat,  and 
presently  gargle  with  water  made  bright  pink  with  Condy's  (red 
cross)  remedial  fluid. 


RULES— HASTINGS  ASSOCIATION  209 

Smallpox 

"  Is  to  be  dealt  with  in  all  respects  like  scarlet  fever, 
with  the  substitution  for  camphorated  oil  of  a  skin 
dressing  of  charcoal  powder  and  olive  oil,  mixed  to  the 
consistency  of  paint,  and  applied  with  a  brush.  Spots 
kept  covered  with  this  will  not  pit.  No.  4  rule  must 
be  applied  in  smallpox  cases  not  less  than  six  weeks 
from  first  discovery." 

Typhoid  Fever 

"  This  disease,  which  is  of  an  infectious  nature,  is 
easily  prevented  from  spreading  if  proper  means  be 
taken  to  remove  the  original  source  of  infection,  to 
isolate  the  patients,  and  to  destroy  all  emanations 
from  their  persons.  For  this  purpose  the  following 
recommendations  have  been  compiled  from  the 
best  authorities  on  the  subject,  by  direction  of  the 
rural  sanitary  authority  of  the  Clifton  Union,  and 
are  adopted  without  any  change  by  the  Sanitary  Aid 
Association  for  the  Borough  of  Hastings. 

1.  If  a  case  of  enteric,  typhoid,  gastric,  or  low 
fever  (different  names  applied  to  the  same  disease) 
appear  in  your  house,  send  immediate  information 
thereof  to  the  Medical  Officer  of  Health  of  the  district. 

2.  Have  your  house  inspected  by  a  competent 
person,  and  make  sure  that  no  sewer  or  drain  gas  can 
enter  into  any  part  of  it.  Any  defect  of  this  may 
render  you  liable  to  infection  from  a  case  of  fever  at  a 
distance  from  your  residence. 


PREVENTION  OF  EPIDEMICS 


3.  Have  your  water  supply  for  domestic  use  ex- 
amined, and  if  in  the  slightest  degree  contaminated  with 
sewage  matter,  immediately  discontinue  the  use  of  it. 
Rain  water  received  in  cisterns  or  barrels  above  ground, 
and  filtered  through  a  common  charcoal  filter,  is  always 
safe.  Water  contaminated  with  sewage  derived  from 
an  infected  source  is  one  of  the  most  common  causes 
of  the  disease. 

4.  Let  the  patient  be  isolated  in  a  well  ventilated 
room,  without  carpets  or  curtains,  and,  if  possible,  at 
the  top  of  the  house. 

5.  Let  all  discharges  from  the  patient,  especially 
those  from  the  bowels,  be  received  into  a  disinfectant ; 
the  most  convenient  are  chloralum  or  Calvert's  powder. 
A  piece  of  gutta-percha  sheeting  or  oilcloth  should  be 
placed  under  the  blanket,  under  the  breach  of  the 
patient,  to  prevent  the  discharges  soaking  into  the 
bed. 

6.  The  bed  and  body  linen,  and  all  other  infected 
clothing,  should  be  plunged  in  water  containing  four 
ounces  of  Calvert's  carbolic  acid  (No.  5)  to  every 
gallon  of  water,  and  afterwards  boiled  before  being 
washed. 

7.  As  soon  after  recovery  as  the  patient  is  able  to 
bear  it,  he  should  take  a  tepid  bath,  or  be  washed  with 
warm  water  and  carbolic  acid  soap  ;  he  may  then 
re-enter  the  family  with  safety. 

8.  Attendants  on  the  sick  should  be  scrupulously 
clean,  and  frequently  wash  their  hands  with  a  disin- 
fectant ;  and  they  should  carefully  abstain  from  touching 


;?  ULES—HA  S  TINGS  A  SSOCIA  TION 


any  article  used  for  the  food  of  man,  such  as  milk, 
etc.  Their  personal  clothing  should  be  treated  as 
infected  articles. 

9.  Any  article  of  food  which  has  been  exposed  to 
infection  in  the  patient's  room  should,  when  not  con 
sumed  by  the  patient,  be  destroyed. 

10.  Every  closet  in  the  house,  and  every  eject 
leading  into  a  drain,  should  be  disinfected  twice  daily 
by  throwing  into  it  a  handful  of  green  copperas.  As 
the  germs  of  this  disease  are  most  generally  dissem- 
inated by  means  of  the  drains,  every  system  of  drains 
receiving  the  evacuations  of  a  typhoid  patient  should 
be  kept  constantly  charged  with  this  inexpensive 
chemical. 

1 1.  As  some  persons  from  peculiarity  of  constitution 
take  this  disease  in  an  extremely  mild  form,  hardly 
recognisable  as  fever,  all  persons  residing  in  a  house 
containing  a  typhoid  patient,  who  are  suffering  from  the 
slightest  indisposition,  and  especially  if  it  is  attended 
with  diarrhoea,  should  confine  themselves  to  the 
house,  treat  their  own  evacuations  as  infected,  and 
scrupulously  abstain  from  using  their  neighbour's 
closets.  Persons  of  this  class  are  often  the  means 
of  spreading  this  and  other  diseases  in  public  factories, 
where  closets  are  used  in  common.  All  such  closets 
should  be  at  all  times  flushed  and  disinfected  twice 
daily. 

12.  Good  ventilation  is  the  best  disinfectant  of  the 
air  of  the  sick-room. 

13.  On  the  recovery  or  removal  of  a  patient,   all 


PREVENTION  OF  EPIDEMICS 


floors,  walls,  and  ceilings  should  be  fumigated,  scraped, 
and  cleaned.  For  fumigating  infected  rooms  and  their 
contents,  nothing  is  better  than  sulphur.  A  quarter 
of  a  pound  of  brimstone,  broken  into  small  pieces, 
should  be  put  into  an  iron  dish  (or  the  lid  of  an  iron 
saucepan,  turned  upside  down),  supported  by  a  pair  of 
tongs  over  a  bucket  of  water.  The  chimney  and  other 
openings  are  then  closed  with  paper  pasted  on,  and  a 
shovelful  of  live  coals  is  put  upon  the  brimstone.  The 
door  is  then  quickly  shut,  the  crevices  covered  with 
paper  and  paste,  and  the  room  kept  closed  for  five  or 
six  hours.  After  this  a  thorough  cleansing  should  be 
effected  ;  everything  washable  should  be  washed,  and 
all  other  things  be  cleansed  by  proper  means. 

14.  Any  further  advice  of  a  public  character,  re- 
quired for  carrying  out  the  above  or  other  sanitary 
precautions,  will  be  given  on  application  to  the  Medical 
Officer  of  Health  or  Inspector  of  Nuisances  of  the 
district." 

Penalties 

"  I .  Catching  or  infectious  diseases  are  scarlet  fever, 
smallpox,  typhus,  typhoid,  and  relapsing  fevers,  and 
measles  [diphtheria  and  whooping  cough]. 

2.  By  the  Sanitary  Act  of  1866,  a  penalty  of  ^5  is 
inflicted  on  persons  who  wilfully  or  negligently  are 
the  means  of  spreading  infectious  and  contagious 
diseases  ^mong  their  friends  or  neighbours. 

3.  It  is  illegal  to  use  any  public  cab  for  the  con- 
veyance of  a  patient  to  a  hospital  or  anywhere  else 


PENALTIES  213 


without  telling  the  driver  that  it  is  a  case  of  infectious 
disease. 

4.  The  driver  of  a  cab  may  refuse  to  take  any  such 
person  unless  he  is  paid  a  sum  of  money  sufficient  to 
defray  the  expenses  of  disinfecting  his  cab. 

5.  Any  cabman  taking  another  fare  after  conveying 
an  infected  person,  without  previously  disinfecting  his 
cab,  is  liable  to  a  penalty  of  ^5. 

6.  It  is  illegal  for  an  infected  person  to  go,  or  for 
any  person  to  take  or  send  anyone  suffering  from  an 
infectious  disease,  to  any  public  place,  such  as  the 
waiting-room  of  a  hospital  or  a  dispensary,  or  to  a 
school,  or  a  church,  or  a  chapel,  or  a  theatre,  or  omni- 
bus or  other  public  carriage,  so  as  to  endanger  any 
other  persons,  whether  adults  or  children. 

7.  It  is  also  illegal  for  any  person  to  give,  lend, 
sell,  or  move  to  another  place,  or  expose  any  bedding, 
clothing,  rags,  or  other  things  which  may  have  become 
infected  and  are  liable  to  convey  any  contagious  dis- 
eases to  another  person,  unless  such  things  have  been 
previously  disinfected. 

8.  It  is  also  illegal  to  let  any  house,  room,  or  part 
of  a  house,  in  which  any  person  has  been  ill  with  any 
infectious  disease,  until  it  and  all  articles  in  it  have 
been  properly  disinfected.  The  same  law  also  applies 
to  public -houses,  hotels,  and  lodging-houses.  The 
penalty  for  disobedience  in  these  cases  is  ^20. 

9.  The  means  of  conveying  persons  to  the  fever 
hospital  or  smallpox  hospital  ■  can  be  ascertained  by 
applying  to  the  Medical  Officer  of  Health." 


APPENDIX 

HOSPITAL    PLANS 


THE  HEATHCOTE  HOSPITAL,   LEAMINGTON  i 

"This  hospital  was  erected  in  1889  by  the  Warwick  Joint  Hospital 
Board,  the  constituent  authorities  of  the  district  being  the  urban 
districts  of  Leamington  Spa,  Warwick,  Kenilworth,  Lillington,  and 
Milverton,  and  the  rural  sanitary  district  of  Warwick  Union. 
Since  the  formation  of  the  joint  district,  the  districts  of  LiUington 
and  Milverton  have  been  amalgamated  with  the  borough  of 
Leamington. 

The  site  is  six  acres  in  extent,  two  and  a  half  acres  of  which 
are  enclosed  and  appropriated  to  the  hospital  use.  It  stands  on 
high  ground  in  the  middle  of  open  fields,  and  is  about  midway 
between  the  towns  of  Warwick  and  Leamington. 

The  population  within  the  joint  district  was,  when  the  hospital 
was  erected,  about  55,000,  and  of  this  number  some  44,000 
were  within  a  radius  of  three  miles  from  the  hospital  site. 

The  area  of  the  district  is  44,507  acres,  and  its  ratable  value 
;^34o,ooo.  The  accommodation  provided  is  equal  to  one  in 
every  2000  of  population. 

The  buildings  are  four  in  number,  and  each  is  entirely  detached 
from  the  remainder.     They  are — 

1.  The  administration  block  ; 

2.  The  isolation  block  ; 

3.  The  ward  block ;  and 

4.  The  laundry  block. 

The  site  is  enclosed  on  three  sides  by  a  high  wooden  fence  ; 
the  front  towards  the  high  road  having  a  dwarf  wall  and  an  iron 
railing. 

The  two  blocks  occupied  by  patients  and  the  laundry  block 

^  Read  in  the  Architectural  Section  of  the  Seventh  International  Congress  of 
Hygiene  and  Demography,  held  in  London,  August  1891,  by  Keith  D. 
Young,  F.R.I.B.A. 


2iS  PREVENTION  OF  EPIDEMICS 

are  each  40  feet  distant  from  the  boundary,  and  an  inner  fence  at 
a  distance  of  40  feet  from  the  front  gates  prevents  patients  from 
approaching  too  near  the  latter. 

The  administration  block  is  the  only  one  of  the  four  buildings 
which  is  two  storys  in  height,  the  rest  being  one  story  only.  It 
contains  on  the  ground  floor  a  sitting-room  for  the  matron  and 
nurses ;  a  room,  with  a  lavatory  and  w.c.  attached,  for  medical 
officers ;  linen  room,  w.c.  for  nurses,  kitchen,  scullery,  and  larder, 
with  wood  and  coal  stores,  and  servants'  w.c.  in  the  yard.  At  one 
corner  of  the  kitchen  is  a  serving  hatch,  opening  into  a  covered 
porch,  at  which  the  meals  for  the  patients  are  given  out. 

On  the  upper  floor  are  bedrooms  for  the  matron,  nurses,  and 
servants,  and  a  bath-room. 

The  Isolation  Block  is  divided  into  two  equal  parts  by  a  wall, 
and  the  arrangements  on  one  side  of  the  wall  are  an  exact  counter- 
part of  those  on  the  other  side,  the  entrance  to  one  side  being  on 
the  east,  and  that  to  the  other  side  on  the  west. 

Each  half  of  the  building,  therefore,  contains  a  large  ward  for 
three  beds,  two  small  wards  for  one  bed  each,  a  nurses'  duty-room, 
and  a  w.c.  and  slop-sink.  These  rooms  communicate  with  each 
other  by  way  of  an  open  verandah,  roofed  over  at  the  top,  but 
quite  open  in  front. 

Each  large  ward  is  36  feet  long  by  18  feet  wide,  the  smaller 
wards  being  18  feet  by  12  feet,  and  all  are  12  feet  high.  The 
allowance  of  floor  space  is  216  feet  per  bed,  and  of  cubic  space 
2592  feet  per  bed.  The  large  wards  are  lighted  by  three  windows 
at  each  end,  the  smaller  ones  by  one  window  on  each  side,  being 
in  the  proportion  of  one  square  foot  of  window  surface  to  about 
65  feet  of  cubic  space.  The  windows,  which  form  the  principal 
means  of  ventilation,  are  divided  into  two  parts  by  a  transom 
which  is  fixed  about  i  foot  6  inches  down  from  the  head  of  the 
frame.  Below  the  transom  are  ordinary  double  hung  sashes  pro- 
vided with  a  deep  bottom  rail  and  a  cill  board,  which  permits  of 
the  lower  sash  being  raised  and  a  current  of  air  admitted  in  a 
vertical  direction  between  the  two  sashes,  at  the  same  time  pre- 
venting free  access  of  air  at  the  cill  level.  Above  the  transom  is  a 
'hopper  light,'  hung  on  hinges  at  the  bottom  to  fall  inwards, 
and  provided  with  glazed  cheeks  at  the  sides  to  prevent  down 
draughts. 

In  addition  to  the  windows,  openings  are  made  at  the  floor- 
level    behind    each    bed,    and    provided    with     Ellison's     radiator 


APPENDIX  219 


ventilators ;  there  is  also  an  extraction  flue  in  each  ward  carried 
up  alongside  the  smoke  flue,  from  which  it  is  separated  by  iron 
plates.  The  inlet  to  the  flue  is  at  the  ceiUng  level,  and  a  Bunsen 
burner  is  provided  with  a  view  to  produce  an  upward  current  when 
the  fire  is  first  lighted. 

The  wards  are  each  provided  with  a  Boyd's  hygiastic  ventila- 
ing  grate ;  these  grates  have  at  the  back  of  the  fire  an  air  chamber 
which  is  supplied  with  fresh  air  from  the  outside.  The  air,  being 
warmed  by  contact  with  the  heated  fire-brick  back  of  the  stove, 
passes  into  the  room  through  a  grating  above  the  fireplace. 

The  walls  of  the  ward  are  lined  to  a  height  of  5  feet  with 
tinted  glazed  bricks,  above  which  they  are  plastered  and  dis- 
tempered. The  floors  are  laid  with  yellow  deal  in  3  feet  widths, 
ploughed  and  tongued. 

The  vertical  angles  of  the  walls,  the  horizontal  angles  at 
the  junction  of  floors  and  walls,  and  of  walls  and  ceilings,  are  all 
rounded,  so  also  are  all  the  angles  of  door  panels  and  of  the 
windows,  and  in  the  finishing  of  the  doors  and  windows  rounded 
fillets  only  are  used,  no  recessed  mouldings  being  used  any- 
where. 

The  nurses'  duty -room  is  provided  with  a  small  range  with 
oven  and  boiler,  and  hot  water  is  laid  on  from  the  latter  to  the 
sink,  the  movable  bath,  in  corridor,  and  the  slop-sink.  There 
is  also  in  this  room  a  small  dresser  and  a  glazed  porcelain  sink. 

Outside  the  duty-room  is  a  recess,  where  the  movable  bath 
stands.  A  glazed  fireclay  sink  let  into  the  floor  takes  the  waste, 
and  taps  fixed  to  the  wall  afford  the  supply  of  hot  and  cold  water. 

The  water-closet  and  slop-sink  are  placed  in  projecting  build- 
ings, entered  from  the  verandah.  The  walls  of  these  offices  are 
lined  with  glazed  bricks,  and  the  floors  are  of  cement.  The  slop- 
sinks  are  of  porcelain,  provided  with  a  flushing  rim,  in  addition  to 
the  hot  and  cold  water  taps.  The  closets  are  Hellyer's  pedestal 
hygienic,  the  trap  and  basin  being  made  in  one  piece,  of  porcelain, 
and  are  fitted  with  3-gallon  flushing  cisterns,  and  hard  wood  rim 
seats  hinged  at  the  back. 

Ward  Block. — This  building  is  entered  from  the  centre,  and 
affords  accommodation  for  twelve  patients,  all  of  one  disease,  the 
beds  being  equally  divided  between  the  two  sexes.  In  the  open 
porch  at  the  entrance  are  two  doors  \  one  of  these  gives  access  to 
the  entrance  lobby,  the  other  being  an  outer  door  to  the  bath- 
room.    The  object  of  the  latter  is  to  enable  a  patient  on  being 


PREVENTION  OF  EPIDEMICS 


discharged,  to  leave  the  building  directly  from  the  bath-room.  The 
bath-room  thus  becomes  a  discharging-room  ;  not  perhaps  an  ideally- 
perfect  arrangement,  but  certainly  a  better  one  than  if  the  patient 
had  to  re-enter  the  ward  after  his  final  bath. 

To  the  left  of  the  entrance  is  a  small  cupboard  with  a  window 
for  food,  and  opposite  are  cupboards  for  patients'  ward  clothes  and 
linen.  Between  the  wards  is  the  nurses'  duty-room,  in  which  is  a 
small  range  with  boiler  for  supplying  hot  water  to  the  bath,  sinks, 
and  lavatory  basins,  a  dresser,  and  a  porcelain  sink. 

The  wards  are  each  of  them  T^(i  feet  long  and  26  feet  wide,  and 
contain  six  beds  each.  To  each  bed  is  allotted  a  floor  space  of 
156  feet,  and  a  cubic  space  of  2028  feet,  and  the  distance  from 
centre  to  centre  of  each  bed  is  1 2  feet.  The  window  area  is  in 
the  proportion  of  about  i  foot  of  window  to  every  60  feet  of  cubic 
space.  The  means  of  ventilation  are  similar  to  those  adopted  in 
the  isolation  block.  The  grates  also  are  similar,  but  in  these 
wards  they  are  placed  in  pairs,  back  to  back,  in  the  centre  of  the 
floor,  with  descending  flues  carried  under  the  floor  to  vertical 
chimneys  in  the  outer  wall.     The  latter  are  swept  from  the  outside. 

The  water-closets  and  slop-sinks  are  placed  in  the  projecting 
buildings  at  the  end  of  the  wards,  from  which  they  are  separated 
by  cross-ventilated  lobbies. 

The  construction  of  these  wards,  as  regards  internal  finishing  of 
floors  and  wall  surfaces,  etc.,  is  in  all  respects  similar  to  that  of  the 
isolation  block. 

A  speaking-tube  connects  the  duty- room  with  the  administra- 
tion block. 

The  laundry  consist  of  a  wash-house  fitted  with  the  usual 
appliances  for  washing,  an  ironing-room,  and  a  drying-room  heated 
by  the  flue  of  the  ironing  stove,  and  fitted  with  a  radial  drying 
horse.     Adjoining  is  a  w.c.  and  a  coal  store. 

The  disinfecting-house  is  divided  into  two  parts  by  a  brick  wall. 
The  apparatus,  which  is  one  of  Washington  Lyon's  high-pressure 
steam  machines,  projects  on  each  side  of  this  wall,  so  that  the 
infected  clothes  are  put  in  one  chamber,  and  when  disinfected  are 
taken  out  by  the  door  in  the  other  chamber. 

The  mortuary  is  a  plain  sky-lighted  room,  arranged  for  use 
when  necessary,  as  a  post-mortem -room.  The  ambulance  house 
affords  accommodation  for  a  one-horse  ambulance. 

Drainage  afid  Water  Supply. — The  drainage  system  is  a  dual 
one,  the  rain  water  being  separated  from  the  sewage,  and  stored  in 


APPENDIX  221 


a  tank  for  use.  The  drains  are  all  laid  with  glazed  stoneware 
pipes  jointed  with  cement,  with  manholes  at  each  junction  and 
change  of  direction.  Each  length  of  pipe  between  the  manholes 
was  separately  tested  with  water  before  being  covered  up,  and  all 
the  pipes  are  laid  on  and  partly  embedded  in  concrete.  At  the 
end  of  every  length  of  drain  is  a  Doulton's  30-gallon  automatic 
flushing  tank,  and  at  the  outfall  to  the  public  sewer  is  a  large 
flushing  tank  fixed  by  the  town  authorities.  These  flushing  tanks 
were  specially  necessary  in  this  case,  as  not  only  is  the  quantity  of 
sewage  discharged  at  one  time  necessarily  small,  but  the  sewer  con- 
veying the  hospital  sewage  to  the  town  sewers  has  to  traverse  a 
long  distance  before  it  comes  near  any  other  buildings.  The  soil 
pipes  are  carried  up  above  the  eaves  of  roofs,  retaining  their  full 
diameter,  as  ventilating  shafts. 

The  rain  water  from  the  roofs  is  all  collected  into  an  under- 
ground tank,  first  passing  through  a  filter  chamber  formed  partly 
of  coarse  and  fine  gravel,  and  partly  of  charcoal.  From  the  tank 
it  is  pumped  for  use  in  the  scullery  of  the  administration  block  and 
the  wash-house. 

The  cost  of  the  hospital  was  as  follows  : — 

£      s.     d. 

1.  Land  ....        900     o     o 

2.  Buildings,    including    laundry    fittings, 

disinfecting  apparatus,  roads,  paths, 
fences,  drains,  and  professional 
charges        .... 

3.  Gas-mains,  from  nearest  point  up  to  site 

4.  Water-mains  .... 

5.  Sewer  .... 

6.  Furniture        .... 


635 

10 

6 

84 

4 

4 

161 

10 

1 1 

299 

4 

9 

293 

17 

7 

^9374     8      I 

To  meet  this  outlay,  loans  were  obtained  from  the  Loans  Com- 
missioners to  the  extent  of  ^9316  at  3  J  per  cent,  repayable  in 
thirty  years.  The  interest  and  repayment  of  principal  amounts  to 
an  annual  sum  of  ^630,  which  is  met  by  a  rate  equal  to  seven- 
sixteenths  of  a  penny  in  the  pound. 

As  regards  cost  of  maintenance,  it  is  not  very  easy  to  arrive  at 
a  definite  figure  in  regard  to  a  hospital  which  is  liable  to  be 
occupied  or  not  in  so  absolutely  uncertain  a  way  as  this ;  but 
assuming  the  wards  were  empty  for  twelve  months  continuously,  it 


PREVENTION  OF  EPIDEMICS 


is  estimated  that  the  cost  of  maintenance  for  that  period  would 
amount  to  ^370.  This  sum  includes  the  following  expenses: — 
Clerk,  medical  officer's  retaining  fee,  steward,  matron,  caretaker, 
outdoor  porter,  nurse,  rations  for  residents,  coal,  gas,  and  water, 
rates  and  taxes.  For  the  statistics  as  to  cost  and  for  much  valuable 
information,  I  am  indebted  to  Mr.  Alderman  Wackrill,  the  Chair- 
man of  the  Joint  Board." 

For  permission  to  pubHsh  the  above  information,  for  the  ground 
plans,  and  for  photographs  of  the  hospital,  I  am  indebted  to 
Mr.  Keith  D.  Young,  the  Architect  of  the  hospital,  and '  to  Mr. 
Alderman  Wackrill,  the  Chairman  of  the  Joint  Board. 


HEATHCOTE    INFECTIOUS    HOSPITAL,    LEAMINGTON. 


Administrative  Block. 


Ward  Block. 


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HEATHCOTE    INFECTIOUS    HOSPITAL,    LEAMINGTON. 


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Obroif 


BURGH  OF  WARRINGTON— INFECTIOUS  DISEASES 
HOSPITAL 

This  hospital  was  opened  in  1877,  since  which  date,  however, 
the  amount  of  accommodation  available  has  been  materially 
increased. 

The  site  consists  of  a  somewhat  irregular  oblong,  having 
throughout  a  width  of  195  feet,  and  an  average  length  of  360  feet; 
in  all,  somewhat  over  i^  acres.  It  is  situated  somewhat  over  half 
a  mile  from  the  centre  of  the  borough.  The  soil  is  sand,  some  12 
feet  deep,  overlying  clay. 

The  present  buildings,  together  with  that  part  of  the  recreation 
ground  enclosed  by  them,  cover  about  two-thirds  of  the  site,  leaving 
a  space  at  the  northern  extremity  for  such  further  extension  as  may 
be  found  necessary.     They  consist  of: — 

I..  An  administrative  block. 

2.  Two  ordinary  ward  pavilions,  which  are  connected  with  the 
administrative  block  by  means  of  a  covered  passage  open  at  the 
sides. 

3.  A  special  pavilion  containing  two  wards. 

4.  A  lodge,  v/hich  is  built  close  to  the  hospital  entrance. 

5.  Two  groups  of  buildings :  one  containing  a  laundry,  dis- 
infecting chamber,  ambulance  shed,  mortuary,  and  store  for  wood, 
coals,  etc.  ;  the  other  containing  two  van  sheds,  and  a  store  for 
garden  tools. 

The  administrative  block  is  a  substantial  two-storied  building. 
This  building,  as  well  as  the  ward  pavilions,  is  built  of  brick  with 
stone  facing,  resting  on  a  bed  of  concrete.  The  external  walls  are 
16  inches  thick,  including  a  2  inch  cavity.  In  the  walls  of  the 
wards  this  cavity  intervenes  between  an  outer  layer  of  9  inches,  and 
an  inner  one  of  5  inches.  The  hospital  contains  28  beds  in  all, 
and  it  affords  accommodation  for  the  simultaneous  treatment  of 
patients  of  both  sexes,  suffering  from  three  infectious  fevers. 


224 


PREVENTION  OF  EPIDEMICS 


The  population  in  1881  was  41,456,  and  the  ratable  value  was 
^129,673. 

The  expense  incurred  in  the  construction  and  furnishing  of  the 
hospital  was  as  follows  : — 


Purchase  of  land  for  site  . 

^300 

0 

0 

Release  of  right  in  x\iken  Street    . 

50 

0 

0 

Erection  of  ist  portion  of  Hospital 

2182 

5 

I 

2nd 

3320 

10 

0 

Hot  water  apparatus 

79 

18 

0 

Entrance  gates,  etc. 

95 

0 

0 

Kitchen  range,  grates,  chimney  pieces 

120 

5 

9 

Gasfittings             .... 

80 

18 

0 

Water-fittings        .... 

27 

8 

6 

Furniture,  bedding,  etc.    . 

105 

9 

7 

,,              „          plumbing,    painting,    etc.,    in 

1878-S0 

355 

3 

3 

^6716 

18 

2 

Disinfecting  stove               .              .              .              . 

125 

0 

0 

Ambulance            .... 

74 

0 

0 

;^69i5 

18 

2 

The  above  particulars,  as  well  as  the  plans,  were  copied  by 
permission  of  Dr.  Thorne  Thorne  from  supplement  to  the  Tenth 
Report  of  Medical  Officer  of  Local  Government  Board,  1880-81. 
Re-issued  1893,  where  further  information  may  be  obtained. 


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EALING    LOCAL    BOARD    ISOLATION 
HOSPITAL 


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ISOLATION    HOSPITALt 
1885 


EXPLANATION. 
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ISOLATION     HOSPITAL    EALING. 


STONEHOUSE    ISOLATION    HOSPITAL, 
LANARKSHIRE 


STONEHOUSE  ISOLATION  HOSPITAL, 
LANARKSHIRE 

This  hospital  is  in  course  of  erection.  It  is  one  of  four 
hospitals  to  be  provided  in  the  middle  ward  of  Lanarkshire. 

The  area  of  the  site  is  3  acres,  and  the  feu-duty  ;^i2  per  acre. 
The  population  intended  to  be  served  by  it  is  about  10,000,  and 
the  total  estimated  cost  of  the  hospital  is  ^^5721. 

As  may  be  seen  from  the  ground  plan,  the  hospital  consists  of — 
(i)  An  administrative  block;  (2)  Laundry  and  disinfecting  block; 
and  (3)  Two  ward  pavilions ;  all  detached  and  at  safe  distances 
apart.     Ample  space  is  left  for  future  extension. 

The  administrative  building  has  accommodation  in  excess  of 
the  present  requirements,  thus  providing  for  further  enlargement. 

The  isolation-wards  pavilion,  is,  with  slight  alterations,  in  accord- 
ance with  the  design  recommended  by  the  Local  Government 
Board.  A  verandah  is  not  provided,  bringing  this  part  of  the 
building  perhaps  more  in  keeping  with  the  climate  of  Scotland. 

In  connection  with  and  at  the  entrance  to  the  fever-wards 
pavilion,  rooms  are  provided  for  the  disinfection  of  patients  before 
being  discharged  from  the  hospital.  These  consist  of  an  undress- 
ing-room, a  bath-room,  and  a  dressing-room.  An  additional  w.c,  a 
store-room,  and  coal  cellar  are  also  provided. 

For  plans  and  particulars  of  this  hospital  I  am  indebted  to  Dr. 
M'Lintock,  Medical  Member  of  the  Local  Government  Board  for 
Scotland. 


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ST0NEH0U8E     ISOLATION     HOSPITAL,    LANARKSHIRE. 


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HOSPITAL  FOR  INFECTIOUS  DISEASES,  SHEFFIELD 

The  construction  of  the  hospital  for  the  borough  of  Sheffield 
was  completed  towards  the  end  of  1880. 

The  site  consists  of  a  quadrilateral  piece  of  land,  measuring 
somewhat  over  an  acre  and  a  third,  and  occupying  the  summit  of 
one  of  the  numerous  undulations  which  characterise  Sheffield.  It 
is  situated  about  400  yards  from  the  centre  of  the  borough,  which 
covers  an  area  of  some  30  square  miles.     The  soil  is  clay. 

As  may  be  seen  from  the  ground  plan,  the  hospital  consists  of 
— (i)  An  administrative  block  three  stories  high  in  front;  (2)  Four 
ward  pavilions,  two  stories  high,  with  flat  roofs  which  are  railed  in, 
and  utilised  as  airing  grounds  for  convalescents;  (3)  Two  porters' 
lodges;  (4)  Outhouses  containing  laundry  with  ironing-room  and 
drying-room,  a  disinfecting  chamber,  a  mortuary  and  post-mortem- 
room,  an  ambulance  shed,  and  stabHng. 

The  administrative  block  and  wards  are  built  of  red  brick,  with 
stone  ornamentation.  The  number  of  beds  is  16  in  each  pavilion, 
or  64  in  all. 

The  ward  ceilings  are  flat,  and  there  are  nowhere  any  pro- 
jections favouring  the  accumulation  of  dust.  The  inner  facing  of 
the  walls  is  of  cement,  coloured  with  some  wash  which  can 
frequently  be  renewed.  The  floors  consist  of  pine  planks,  laid 
without  any  interspaces.  The  remainder  of  the  woodwork  through- 
out the  building  is  of  oak.  The  centre  of  each  ward  is  occupied 
by  a  large  stove,  containing  two  open  fireplaces.  Fresh  air,  which 
is  conveyed  from  without  by  means  of  special  shafts  under  the  floor 
on  each  side  of  the  ward,  passes  round  the  fireplaces  and,  after 
being  warmed,  into  the  wards  at  a  height  of  about  6  feet  above  the 
floor.  Another  opening  near  the  ceiling  carries  some  of  the 
vitiated  air  into  the  smoke  flue.  x\bove  each  bed  are  fitted  two 
Sherringham  ventilators  having  direct  communication  with  the 
outer  air  by  means  of  shafts  rising  from  below.  The  windows  are 
arranged  so  that  there  is  one  near  each  corner  of  the  ward.  The 
lower  three  fourths  of  each  window  consists  of  double  hung  sashes, 

229 


PREVENTION  OF  EPIDEMICS 


and  the  upper  quarter  of  a  pivot  hung  frame,  which  easily  opens 
by  means  of  Beanland's  patent  quadrant. 

The  population  in  1881  was  estimated  at  285,621,  and  the 
ratable  value  at  ;^934,32o. 

The  total  expenditure  incurred  in  the  construction  of  the 
hospital  (including  the  preparation  of  the  site,  the  prizes  for  designs 
etc.),  was  as  follows: — 


Purchase  money  of  site  and  interest  thereon 
Expense  of  conveyance 
Cost  of  preparing  site 


;^i,8o8     8      2 

8    17      4 
1,816     4     o 


Cost  of  Construction. 

Preliminary  expenses 
Construction  of  building,  etc. 
Clerk  of  works    . 
Architect's  commission   . 
Disinfecting  apparatus     . 


no  14  9 
16,092  15  3 
257  4  II 
908  4  II 
100  o   o 


£^^ 


The  above  particulars,  as  well  as  the  plans,  were  copied  by 
permission  of  Dr.  Thorne  Thorne,  from  the  Supplement  to  the 
Tenth  Annual  Report  of  the  Local  Government  Board,  re-issued 
1893,  pp.  241-243,  where  further  information  may  be  obtained. 


HOSPITAL    FOR    INFECTIOUS    DISEASES  ,  SHEFFI  ELD 


10  s  0      10  x^    ao   40     so 

I  M  M   Ul   U|   I   I  I  -I  I =i 


BLOCK  -    PLAN 

Scale   or  Feet  . 

100 


S  .Ij  .  Swcarrv  ArcJv^ 
Sh£0veLciJ}ec16.8O. 


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DUNOON    AND    KTLMUN    ISOLATION 
HOSPITAL 


DUNOON  AND  KILMUN  ISOLATION  HOSPITAL 

The  following  plans  were  submitted  to  the  Dunoon  Combina- 
tion Hospital  Committee  for  the  Isolation  Hospital  intended  to  be 
erected  for  the  burgh  of  Dunoon  and  the  landward  parts  of  the 
parishes  of  Dunoon  and  Kilmun.  Sketch  A  was  selected  by  the 
committee  as  meeting  the  requirements  of  the  locality. 

The  site  selected  is  about  two  acres  in  extent  on  a  slope  of 
porous  soil  overlying  clay  slate,  with  a  south  -  eastern  exposure. 
It  is  within  a  mile  of  the  centre  of  the  burgh,  which  covers  an 
area  of  about  iioo  acres,  and  is  also  in  the  most  central  position 
for  the  whole  district  to  be  served  by  the  hospital. 

The  area  of  the  whole  district  is  about  44,577  acres.  The 
population  in  1891  was  8683,  of  whom  5283  reside  in  the  burgh 
of  Dunoon,  the  majority  of  the  remaining  3400  being  in  villages 
along  the  coast,  within  8  miles  of  the  proposed  hospital.  The 
population  is  probably  doubled  during  the  summer  months.  A  few 
scattered  families  live  at  distances  up  to  about  25  miles  from  the 
hospital. 

The  ratable  value  of  the  district  is  about  ^^82,000. 

As  may  be  seen  from  Sketch  A,  the  proposed  hospital  is  to 
consist  of — (i)  An  administrative  building  and  outhouses;  (2)  One 
detached  pavilion  with  two  wards  of  four  beds  each,  intended  for 
the  reception  of  persons  suffering  from  the  more  prevalent  diseases, 
such  as  scarlet  fever;  (3)  Two  detached  smaller  paviUons  or 
cottages  with  two  wards  each,  each  ward  having  sufficient  room 
for  two  patients.  These  are  intended  to  be  used  for  the  less 
prevalent  diseases,  such  as  diphtheria  or  typhoid  fever,  or  as  private 
wards,  as  circumstances  may  require. 

The  number  of  beds  provided  is  16,  and  the  building  is  so 
arranged  that  persons  of  both  sexes  suffering  from  three  different 
infectious  diseases  may  be  isolated  simultaneously  in  the  hospital. 
The  number  of  beds  is  in  excess  of  the  ordinary  requirements  of 
such  a  small  population.     This  was  considered  necessary  owing  to 

232 


PONOOM' Combination- 
Fever- Hospital. 

SKETCH    A,    A3    INTENDED  TO  3E 
ERECTED. 


•Block-Plan- 


PROPOBEO  NEW  ROAO. 


.at^^^ty^^^4^^t'-/e^A/^>^^^?^:^f.?^'Jv^H'.■^-y;Jl/^;^v^■!V-^)t'^v^ 


ftrfr 


Fever 
Wards 


Administrative   Block 


50  60  70 


t  I  I 


SCALE    OF     FEET. 


APPENDIX  233 

the  increase  of  the  population  during  the  summer  months.  From 
its  position  in  regard  to  a  number  of  large  towns,  and  being  a 
popular  seaside  resort,  the  district  is,  like  other  watering  places, 
liable  to  become  frequently  infected  by  visitors  suffering  or  recover- 
ing from  infectious  diseases. 

The  large  wards  in  the  fever  pavilion  are  26  feet  long  by  22 
feet  broad.  The  small  wards  in  the  isolation  pavilions  are  2  2  feet 
long  by  13  feet  broad.  A  height  of  about  14  feet  is  therefore 
necessary  in  order  to  provide  a  cubic  space  of  2000  feet  per 
patient. 

The  following  are  the  dimensions  of  the  other  principal  apart- 
ments: — Nurses'  day-rooms  15  feet  by  10  feet,  kitchen  15  feet  6 
inches  by  13  feet,  doctor's  room  13  feet  by  9  feet,  matron's  parlour 
1 3  feet  by  1 1  feet,  2  bedrooms  1 3  feet  by  1 1  feet,  i  bedroom  9 
feet  by  7  feet,  mortuary  14  feet  by  11  feet,  ambulance  shed  14  feet 
by  II  feet,  washing-house  13  feet  by  1 1  feet,  disinfecting-room  13 
feet  by  II  feet. 

In  Sketch  B  the  pavilions  are  also  three  in  number,  and  con- 
tain two  wards  with  two  beds  in  each.  The  future  extension  of 
the  wards  was  intended  to  be  carried  out  in  a  different  manner. 

After  this  was  accomplished,  each  pavilion  would  consist  of  a 
male  and  female  ward  of  two  beds  each,  for  acute  cases,  and  of  a 
male  and  female  ward  of  three  beds  each  for  convalescents,  raising 
the  total  number  of  beds  to  thirty. 

The  wards  in  this  plan  are  20  feet  long  by  15  feet  broad.  A 
height  of  about  13  feet  6  inches  is  therefore  necessary  in  order  to 
provide  a  cubic  space  of  2000  feet  per  patient.  The  dimensions 
of  the  other  principal  apartments  are  as  follows,  viz.  : — Nurses'  day- 
rooms  12  feet  6  inches  by  9  feet,  kitchen  15  feet  by  12  feet, 
matron's  parlour  1 3  feet  by  1 1  feet,  doctor's  room  1 3  feet  by  i  o 
feet,  2  bedrooms  13  feet  by  11  feet,  2  bedrooms  11  feet  by  11  feet, 
I  bedroom  9  feet  6  inches  by  6  feet,  mortuary  14  feet  by  9  feet  6 
inches,  ambulance  shed  14  feet  by  10  feet,  disinfecting-room  12 
feet  by  9  feet,  washing-house  12  feet  by  12  feet,  laundry  12  feet 
by  12  feet. 

There  is  also  a  discharging-room,  and  store  for  clean  clothes,  and 
nurse's  dressing  -  room  detached  both  from  the  wards  and  from 
the  administrative  building.  This  building  is  intended  for  the  final 
baths  and  disinfection  of  patients  before  being  sent  to  their  homes. 
It  is  also  intended  to  be  used  as  a  dressing-room  for  nurses 
before  going  on  duty,  and  after  leaving  the  wards. 


234  PREVENTION  OF  EPIDEMICS 

In  the  discharging-rooms  the  dimensions  are  as  follows,  viz. — 
Undressing-rooms  {a)  i  o  feet  by  8  feet,  {f)  i  o  feet  by  6  feet,  {c)  1 1 
feet  by  lo  feet,  shower  bath-room  lo  feet  by  4  feet  6  inches, 
patients'  bath-room  10  feet  by  9  feet,  nurses'  bath-room  10  feet  by 
10  feet,  patients'  dressing-room,  10  feet  by  8  feet,  nurses'  dressing- 
room  10  feet  by  8  feet,  clothes  store  18  feet  6  inches  by  8  feet. 

The  whole  building  is  to  be  constructed  of  stone  and  lime,  with 
hollow  walls. 

The  estimated  cost  is  as  follows : — 

Plan  A. 


I  Pavilion,  8  beds 

^815 

0 

0 

I        „         4     „ 

615 

0 

0 

-'-        )j          )) 

615 

0 

0 

Administration  block  and  outhouses 

lOIO 

0 

0 

^^3055 

0 

0 

Laying  off  grounds           .              .        ^^30 

0 

0 

Enclosures          .               .              .          120 

0 

0 

Furniture             ..              .    .          .          175 

0 

0 

325 

r\ 

r\ 

u 

\J 

^3380 

0 

0 

Plmi  B. 

3  Pavilions,  each  of  4  beds,  ;^63o  each  . 

^1890 

0 

0 

Administrative  block  and  outhouses 

1200 

0 

0 

;^309o 

0 

0 

Laying  off  grounds           .               .        ;^30 

0 

0 

Enclosures          .               .              .          120 

0 

0 

Furniture             .              .              .140 

0 

0 

0  C\r\ 

Q 

0 

Additional  extension,  6  beds,  as  per  Plan,  1 

Lo  each 

^  Kj\J 

pavilion,  ;^2  6o,  or,  18  beds 

• 

1560 

0 

0 

^4940 

0 

0 

Discharging-room 

500 

0 

0 

30  beds  at  p^i8i  :  6  :  8. 

£SAAo 

0 

0 

For   the   plans   and   estimate   of  cost   I   am  indebted  to    Mr. 
Bryden,  the  architect. 


D^iM'QONi  Combination- 

•FEVER    HOSPITAL- 
"SKETCH  B" 


Block  Plan. 


Possible  Extension 


B„c 

ll'l^" 

ii_^ 

V. 

S^ 

Sj 

li 

&  1  S  : 

3S 

Jrti^-, 

W        P0S3iai£  EXTTNSION 


i.::;::s/f^:;.vi^:; 


Plan  of  Ground   Floor.     Administrative   Block. 


Plam  ofUpferFloor 


60  70  80  90 


/f,^rfJ.Br't/^n 


Scale   cf    Feet. 


PLANS  OF  ISOLATION   HOSPITALS  RECOMMENDED 
BY  THE  LOCAL  GOVERNMENT  BOARD 

On  the  Provision  of  Isolation  Hospital  Accommodation  by  Local 
Sanitary  Authorities 

English  communities  nowadays  recognise  the  advantage  of  Isolation 
Hospitals  as  a  means  of  preventing  the  spread  of  infectious  diseases 
from  persons  who  cannot  be  properly  isolated  in  their  own  homes. 
But  too  often  the  provision  of  such  hospitals  is  put  off  until  some 
infectious  disease  is  immediately  threatening  or  has  actually  in- 
vaded a  district.  It  cannot  be  too  clearly  understood  that  an 
Isolation  Hospital,  to  fulfil  its  proper  purpose  of  sanitary  defence, 
ought  to  be  in  readiness  beforehand.  During  the  progress  of  an 
epidemic  it  is  of  little  avail  to  set  about  hospital  construction. 
The  mischief  of  allowing  infection  to  spread  from  first  cases  will 
already  have  been  done,  and  this  mischief  cannot  be  repaired. 
Thus,  hospitals  provided  during  an  epidemic  are  mainly  of  advantage 
to  particular  patients ;  they  have  little  effect  in  staying  the  further 
spread  of  infection.  Moreover,  hospitals  provided  under  such 
circumstances,  to  be  of  any  use,  must  be  large  and  costly ;  and 
their  construction  can  seldom  be  of  a  kind  that  is  suited  in  after 
times  for  the  isolation  requirements  of  their  districts. 

The  present  memorandum  is  designed  to  represent  to  every 
Sanitary  Authority  which  is  without  means  of  isolation  for  first  cases 
of  infectious  sickness  appearing  in  its  district,  the  importance  of 
providing  itself  against  that  event,  and  of  doing  so  before  the 
invasion  of  actual  infection.  It  is  intended  also  to  suggest  to 
Sanitary  Authorities  of  rural  districts,  and  of  small  towns,  the  means 
by  which  they  may  most  advantageously  make  such  provision. 
Some  general  principles  to  be  held  in  view  by  all  authorities  who 
are  about  to  establish  Isolation  Hospitals  for  their  districts  will  be 
illustrated  in  the  course  of  the  memorandum. 


236  PREVENTION  OF  EPIDEMICS 

As  regards  villages. — Large  villages  and  groups  of  adjacent 
villages  will  commonly  require  the  same  sort  of  provision  as  towns. 
Where  good  roads  and  proper  arrangements  for  the  conveyance  of 
the  sick  have  been  provided,  the  best  arrangements  for  village 
populations  is  by  a  small  building  accessible  from  several  villages ; 
otherwise  the  requisite  accommodation  for  (say)  four  cases  of 
infectious  disease  in  a  village  may  at  times  be  got  in  a  fairly  isolated 
and  otherwise  suitable  four-room  or  six-room  cottage  at  the  disposal 
of  the  Sanitary  Authority ;  or  by  arrangement  made  beforehand 
with  some  trustworthy  cottage-holders,  not  having  children,  that 
they  should  receive  and  nurse,  on  occasion,  patients  requiring  such 
accommodation. 

In  towns,  hospital  accommodation  for  infectious  diseases  is 
wanted  more  constantly,  as  well  as  in  larger  amount,  than  in 
villages ;  and  in  towns  there  is  greater  probability  that  room 
will  be  wanted  at  the  same  time  for  two  or  more  infectious  diseases 
which  have  to  be  treated  separately.  The  permanent  provision  to 
be  made  in  a  town  should  consist  of  not  less  than  four  rooms  in 
two  separate  pairs ;  each  pair  to  receive  the  sufferers  from  one 
infectious  disease — men  and  women  of  course  separately.  The 
number  of  cases  for  which  permanent  provision  should  be  made 
must  depend  upon  various  considerations,  among  which  the  size 
and  the  growth  of  the  town,  the  lodgment  and  habits  of  its  popula- 
tion, and  the  traffic  of  the  town  with  other  places,  are  the  most 
important.  There  is  no  fixed  standard  therefore  by  which  the 
standing  hospital  requirements  proper  for  a  town  can  be  measured. 
Furthermore,  it  is  to  be  remembered  that  occasions  will  arise  (as 
where  infection  is  brought  into  several  parts  of  the  town  at  one 
time)  when  isolation  provision,  in  excess  of  that  commonly 
sufficient  for  the  town,  will  become  needful. 

For  a  town  the  hospital  provision  ought  to  consist  of  wards  in 
one  or  more  permanent  buildings,  with  space  enough  for  the  erection 
of  other  wards,  temporary  or  permanent.  Considerations  of  ultimate 
economy  make  it  wise  to  have  permanent  buildings  sufficient  for 
somewhat  more  than  the  average  necessities  of  the  place,  so  that 
recourse  to  temporary  extensions  may  less  often  be  necessary.  And 
in  any  case  it  is  well  to  make  the  administrative  offices  some- 
what in  excess  of  the  wants  of  the  permanent  wards ;  because  thus, 
at  little  additional  first  cost,  they  will  be  ready  to  serve,  when 
occasion  comes,  for  the  wants  of  temporary  extensions. 

Plans  illustrating  the  sanitary  requirements  of  small  hospitals 


APPENDIX  237 


for  infectious  disease  are  arranged  on  three  sheets  accompanying 
the  present  memorandum.  Plan  A,  on  the  first  sheet,  is  that  of  a 
little  building  to  hold  two  patients  of  each  sex.  On  the  second 
sheet  a  plan  and  a  section  (B)  ^  of  a  rather  larger  hospital  building 
are  shown,  providing  for  eight  patients,  with  separation  of  sex,  and 
also  \oi  one  infectious  disease  from  another.  A  convenient  dis- 
position of  buildings  upon  site  is  also  indicated  on  the  same  sheet. 
The  third  sheet  shows  a  plan  and  section  (C)  of  a  small  pavilion 
adapted  to  receive  six  male  and  six  female  patients  suffering  from 
one  kind  of  infectious  disease.  It  will  be  found  that  in  all  the 
plans  proper  standards  of  space  are  observed,  viz.,  not  less  than 
2000  cubic  feet  of  air  space,  than  144  square  feet  of  floor  space, 
and  1 2  linear  feet  of  wall  space  to  each  bed ;  that  means  are  pro- 
vided for  the  adequate  ventilation  and  warming  of  wards,  and  for 
securing  them  from  closet  emanations  and  the  like.  In  plan  A, 
earth-closets,  in  other  plans  water-closets,  are  indicated  as  the 
means  of  excrement  disposal.  The  latter  are  to  be  regarded  as 
preferable  where  efficient  sewers  are  available.  Places  for  washing 
and  ■  disinfection,  and  for  a  mortuary,  are  indicated.  It  will  be 
observed  that  an  interval  of  40  feet  is  everywhere  interposed 
between  every  building  used  for  the  reception  of  infected  persons 
or  things  and  the  boundary  of  the  hospital  site.  This  boundary 
should  have  a  close  fence  of  not  less  than  6  feet  6  inches  in  height, 
and  the  40  feet  of  interval  should  not  afterwards  be  encroached  on 
by  any  temporary  building  or  other  extension  of  the  hospital.  In 
the  construction  and  arrangement  of  such  temporary  buildings  as 
may  at  times  be  wanted  in  extension  of  the  permanent  hospital, 
the  same  principles  should  be  held  in  view. 

In  determining  the  locality  where  an  infectious  hospital  should 
be  placed,  the  wholesomeness  of  the  site,  the  character  of  the 
approaches,  together  with  the  facilities  for  water  supply,  and  for  slop 
and  refuse  removal,  are  matters  of  primary  importance. 

[Sites  for  hospitals  designed  to  receive  smallpox  require  a  very 
much  larger  space  about  them  than  sites  for  other  infectious- 
diseases  hospitals.  Smallpox  hospitals,  as  we  know  them, 
are  apt  to  disseminate  smallpox,  and  their  sites  should 
therefore  be  placed  outside  of  towns,  and  should  indeed  be 
sought  at  places  as  far  distant  from  any  populated  neighbour- 

^  On  the  second  sheet,  B,  plans  and  sections  of  hospital  buildings  are  shown 
providing  for  6  and  lo  instead  of  8  patients,  as  stated  above.  These  plans  also 
are  recommended  by  the  Local  Government  Board. 


23S  PREVENTION  OF  EPIDEMICS 

hood  as  considerations  of  accessibility  permit.      It  has  been 

suggested  that  smallpox  hospitals  may  be  so  constructed  as 

not  to  be  dangerous  to  neighbouring  habitations ;  and  that 

this  can  be  done  by  a  system  of  passing  through  a  furnace 

all  outgoing  air  from  infected  wards  and  places.] 

Useful  information  on  points  of  construction  and  administration 

of  Isolation  Hospitals,  derived  from  experience  of  them  in  various 

parts  of  England  and  Wales,  will  be  found  in  a  report  (C. — 3290) 

of  the  Medical  Department,  1882 — re-issued  in  1884. 

R.  Thorne  Thorne, 
Medical  Officer. 

Local  Government  Board,  Medical  Department, 
Septe7?iber  1892. 


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TARBERT    ISOLATION    HOME 


TARBERT  ISOLATION  HOME 

The  following  plan  was  submitted  for  a  hospital  which  is  in- 
tended to  be  erected  at  Tarbert,  Loch  Fyne.  It  consists  of  an 
administrative  cottage,  wards,  and  outhouses,  all  detached,  and  at 
safe  distances  apart.  There  is  also  space  left  for  additional 
extension,  should  that  be  found  necessary  in  the  future.  The 
ward  block  consists  of  four  rooms.  If  only  one  disease  be  under 
treatment  in  the  hospital,  three  rooms  may  be  occupied  by  patients, 
and  the  remaining  room  by  the  nurse  in  attendance.  If  two 
diseases  such  as  typhoid  fever  and  diphtheria  break  out  at  the  same 
time  in  the  district,  two  patients  suffering  from  one  disease  might 
be  isolated  in  one  ward,  and  two  patients  from  the  other  disease 
in  the  other  ward.  By  closing  the  door  of  the  porch  in  the 
verandah,  all  communication  between  the  two  ends  of  the  hospital 
would  be  prevented,  and  a  room  left  for  the  nurses  attending  to 
each  disease. 

The  site  selected  for  the  hospital  is  within  half  a  mile  of  the 
village  of  Tarbert.  The  area  of  the  whole  district  to  be  served  by 
the  hospital  is  about  50,000  acres.  The  population  is  about  3000, 
of  whom  1900  reside  in  the  village  of  Tarbert.  The  remainder  are 
scattered  over  the  district  at  distances  by  road  up  to  about  fifteen 
miles. 

The  ratable  value  of  the  district  is  about  ;^  14, 745. 

The  estimated  cost  of  the  building  is,  if  of  stone  and  lime,  ;^io5o. 
If  the  wards  were  built  of  stone,  but  the  administrative  cottage  and 
outhouses  of  cement,  the  cost  is  estimated  at  ;;^85o. 

For  the  plans  and  estimate  of  cost  I  am  indebted  to  Mr.  Petrie, 
the  architect. 


240 


TARBERT  ISOLATION 
HOME. 

DRYING  C  R  E  E  N. 


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DR.     BURDON     SANDERSON'S    ANNULAR 
WARD    FOR    SMALLPOX 


R 


DR.  BURDON  SANDERSON'S  ANNULAR  WARD  FOR 
SMALLPOX 

Annular  Ward  for  the  reception  of  12  Smallpox  patients 

The  following  are  architect's  sketches  of  annular  ward  referred 
to  in  Dr.  Burdon  Sanderson's  evidence  before  the  Smallpox  and 
Fever  Hospitals  Commission.  "  The  entrance  from  the  corridor  is 
closed  by  double  spring  doors.  The  corridor  communicates  (i) 
with  the  exterior,  (2)  with  the  mortuary  and  disinfecting  chamber, 
(3)  with  chambers  for  changing  the  clothes  of  visitors  and  nurses; 
consequently  the  corridor  is  regarded  as  infected.  If  desirable  it 
might  be  brought  within  range  of  the  ward  ventilation,  and  used 
as  a  place  of  recreation  for  patients  sufficiently  advanced  in  recovery. 
In  a  building  consisting  of  several  stories,  the  ward  might  be  entered 
from  a  staircase  in  the  central  chamber,  the  construction  of  which 
would  not  interfere  with  the  ventilation." — Smallpox  and  Fever 
Hospitals  Commission  Report,  Minutes  of  Evidence,  Questions 
5488,  5492. 


242 


ANNULAR    WARD    FOR    THE    RECEPTION    OF    12    SMALLPOX 

PATIENTS. 


DR.  J.  BURDON  SANDERSON,  F.R.S.* 


Smallpox  and  Fever  Hospitals  Commission,  Minutes  of  Evidence,  Question  5488. 


INDEX 


Aberdeen,  families  in  houses  of  differ- 
ent sizes,  46 
Admission  book,  177 
Administrative  building,  114 
Air    of   hospital    wards,    contamination 

of,  SS.  74 
Aitken,  Dr,  on  measles,  malignant  type, 

25 

Ambulance  carriage,  186 

drivers,  193 

Station  regulations,  188 
Anthrax,  immunity  from,  13 

bacillus  of,  62,  65 
Antiseptics,  75 

no  protection  against  infection,  jj 
Argyll,    families   in    houses    of  different 

sizes,  46 
Ashpit,  143 

Association,  Private  Sanitary  Aid,  204 
Ayr,  families  in  houses  of  different  sizes,  46 

Bacteriologists  and  Epidemiologists, 

6g,  72 
Bacteriology,  progress  of,  60 
Barker  and  Cheyne,  Drs. ,  on  hardships 

to  the  poor  in  absence  of  Isolation 

Hospitals,  47 
Bath-room,  139 
Beds,  requisite  number  of,  80 

size  of,  144 
Belvidere  Hospital,  visitors'  room,  184 
Bernard,    Dr.,   on   removal   of  patients, 

84 
Billings,  Surg. -Gen. ,  on  vitality  of  scar- 
let fever  infection,  69 
on  temporary  hospitals,  118 
Birdwood,  Dr.,  on  spread  of  smallpox,  6 
Blegdam  Hospital,  bath-room  for  Medical 

Staff,  181 
Bostock,     Surg. -Gen.,     on    spread     of 

smallpox,  40 
Bristowe,  Dr. ,   on  infectious  diseases  in 

general  hospitals,  97 
Brown,  Dr.  Francis,   on  inner  lining  of 

walls,  126 
on  wooden  pavilions,  118 
on  sanitary  zone  round  hospital,  105 


Browning,   Dr. ,  on  spread  of  smallpox, 

51 
Bruce,  Dr.,  on  spread  of  measles,  7 
Burdett,   Mr.,   on  want  of  hospital  pro- 
vision, 4 
on      additional     powers     to    County 
Councils,  87 
Burdon  Sanderson,  Dr. ,  on  antiseptics,  75 
Circular  ward,  plan  of,  appendix,  242 
on  pathology  of  contagium,  57 
on  contagium  of  splenic  fever,  61 

Carpenter,  Dr.,  on  vitality   of  small- 
pox infection,  69 

Carriage,  ambulance,  186 

Cat  disease  and  diphtheria,  65 

Chalmers,  Dr. ,  on  scarlet  fever  and  milk 
supply,  8 

Cholera,  isolation  of,  45 

Cleanliness,  185 

Cohn  and  pure  culture,  60 

Collie,  Dr.,  on  instructions  for  disinfec- 
tion, 171 
on  mortality  from  measles,  23 
on  removal  of  patients,  83 

Collier,   Dr. ,   on  notification  and  isola- 
tion, 51 

Commission  Royal,  on  Fever  and  Small- 
pox Hospitals,  on  period  of  seclu- 
sion, 37 
on      atmospheric      dissemination      of 

disease,  93 
evidence  on  removal  of  patients,  83 

Consumption,  bacillus  of,  64 

Conveyance  of  patients  to  hospital,  82 

Corrosive  sublimate,  162,  165 

County   Councils    as    hospital-providing 
authorities,  87 

Cubic  space,  130 

Danger  to  the  rich,  40 

Dead-house,  143 

Delancey  Hospital,  expenses  of,  78 

Destructor,  143 

Dewar,  Dr.,  on  spread  of  measles,  7 

Diphtheria,  bacillus  of,  65 

mortality  from  at  different  ages,  20 


244 


PREVENTION  OF  EPIDEMICS 


Diphtheria,  spread  of,  8,  41 
Discharging-room,  iii,  139 
Disinfection,  150 

chemical  poisons  for,  161 

Dr.  Gayton  on,  152 

instructions  for,  171 

Dr.  Russell  on,  164 
Disinfecting  apparatus,  Fliigge's,  168 

Koch's  cylinder,  167 

Washington  Lyon's,  169 
Distance     over     which     infection     may 
spread,  90,  93 

removal  of  patients  from  a    distance 
to  hospitals,  82 
District  Committees,  4 
Drainage,  141 

Dreadnought  Hospital  Ship,  120 
Drivers,  ambulance,  regulations  for,  193 
Dudfield,    Dr.,    on    removal   of  patients 

and  spread  of  disease,  50 
Dunoon  and  Kilmun  Combination  Hos- 
pital, plan  of,  appendix,  232 

Ealing  Hospital,  185 

plan  of,  appendix,  226 
Eberth  and  typhoid  bacillus,  67 
Epidemics,  advent  of,  9 

misery  following,  6,  47 

future  epidemics,  30 

Families  in  houses  of  different  sizes,  46 
Faroe  Islands,  measles  at,  24 
Farr,   Dr.,    on    typhoid    fever,    suscepti- 
bility of  children,  17 
on  value  of  each  member  of  the  pop- 
ulation, 33 
Floor,  130 

polishing  and  hardening  of,  124 
space,  130 
Fliigge,  disinfecting  apparatus,  168 
Forfar,   families    in    houses    of   different 

sizes,  46 
Fosbroke,    Mr.    G.    S. ,    on    spread    of 

typhoid  fever,  8 
Furniture,  hospital,  143 
of  Ambulance  Station,  198 
list  of,  for  ward,  147 

Galton,    Sir    Douglas,    on    one-storied 
wards,  104 
on  inner  lining  of  walls,  125 
on  ventilation,  136 
Gayton,  Dr.,  on  disinfection,  164 
on  removal  of  patients,  84 
on  smallpox,  28 
Gull,    Sir  William,    on   typhus  fever   in 
general  hospitals,  98 

Hardships  to  the  poor,  47 

Harness  (horses),  197 

Hastings  Private  Sanitary  Aid  Associa- 
tion, 204 

Heat  as  a  disinfectant,  Drs.  Parsons  and 
Klein  on,  154 


Heat  as  a  disinfectant,  Koch  and  Wolf- 

hugel  on,  160 
Holmes,  Dr.  T. ,   on  infectious  diseases 

in  general  hospitals,  97 
Homerton  Fever  and  Smallpox  Hospital, 

typhus  in,  99 
Horses,   Ambulance  Station,   feeding  of, 

196 
Horsekeepers,  201 
Hospitals,  Isolation — 

administrative  building  of,  114 
barrack  hospitals,   Surg. -Gen.   Billing 

on,  119 
component  parts  of  hospitals,  108 
construction  of  hospitals,  114 
Delancey  Hospital,  78 
distance  from  patients,  82-86 
healthiness  of,  sensitive  test  for,  75 
huts,  3,  106 
ill  kept,  57 
immediate  advantage  should  be  taken 

of,  80 
infection  of  walls  in,  74 
infectious    cases    treated     in    general 

hospitals,  97 
loans  for,  a  good  investment,  40 
management  of,  175 
medical  attendance  in,  175 
most   effective    means    for    preventing 

spread  of  disease,  46 
number  of,  in  England  and  Wales,  4 
number  of  beds  in,  80 
occurrences  in  absence  of,  47 
one-storied  wards,  loi 
prevent  hardship  to  infected  families, 

39 

spread  of  disease,  50 

provision,  inefficiency  of,  3 

rates  for,  a  good  investment,  40 

spread  of  infection  from,  90 

sanitary  zone  round,  90 

site  of,  88,  89 

size  of,  96 

temporary,  106 

width  of  sanitary  zone  round,  93 
Houses,   number  of  families  in  different 

sizes  of,  46 
Howes,    Dr.,    on    infectious    disease    in 
general  wards,  98 

on  hair  mattresses,  144 
Huts, movable, as  Isolation  Hospitals,  106 
Hydrophobia,  13 

Infection — 

agents  of,  particulate,  58 

centres  of,  extinguished,  43 

compared  to  fire,  10 

duration  of,  37 

of  measles  and  whooping  cough,  73 

micro-organisms,  agents  of,  56 

nature  of,  55 

never  extinct  in  towns,  5 

spread  of,  5,  6,  179 


I 


INDEX 


245 


Infection  (continued) — 

spread   of,    prevented    by   removal    of 
patients  to  hospitals,  50 
slower  in  rural  districts,  81 
in  towns  a  grave  danger,  7 
Infectious  diseases,  age  mortality  from,  14 
between  two  fires,  13 
isolated  in  general  hospitals,  97 
mostly  diseases  of  children,  12 
number  of  deaths  from,  in  Scotland,  34 
separate  provision  for,  80 
should    not    be    treated    in     general 
wards,  loi 
Inverness,  families  in  houses  of  different 

sizes,  46 
Investment,    Isolation    Hospital    rates    a 

profitable,  40 
Isolation,    duration    of,    in    fevers    and 
smallpox,  37 
hitherto  neglected,  i 
impossibility  of,  in  small  houses,  46 
means    for,    prominently    before    the 

public,  I 
special  impurities  to  be  guarded  against 
in  an  Isolation  Hospital,  73 

Jones,  Prof. ,  on  inner  lining  of  walls  of 
wards,  126 

Klebs  and  fractional  method,  60 
Klein,  on  disinfection,  154 

on  diphtheria  bacillus,  65 

on  typhoid  bacillus,  67 

on  Streptococcus  scarlatincE,  66 
Koch,  on  Bacillus  tuberculosis,  64 

disinfecting  cylinder  of,  167 

on  disinfection,  160 

improved  method  of,  62 

on  splenic  fever,  62 

Lanark,  families  in  houses  of  different 

sizes,  46 
Laundry,  142 
Leamington   Infectious    Hospital,    plans 

of,  appendix 
Littlejohn,  Dr.,  on  removal  of  patients, 

84 
Lister,  Sir  Joseph,  and  micro-organisms, 

60 
Loans  for  hospitals,  5 
Local     Government     Board,     plans     of 
hospitals  of,  appendix 
report  of  Medical  Officer  of,  8 
return  of  Isolation  Hospitals,  4 
London    Fever    Hospital,    distance    of, 
from  houses,  go 
typhoid  in,   18 
typhus  in,  16 
Loss,  economic,  from  infectious  diseases, 

33 

to  a  family  from  two  cases  of  infecti- 
ous disease,  38 


M'LiNTOCK,   Dr.,   on  spread   of  small- 
pox, 7 
M'Vail,  Dr.,   on  spread  of  scarlet  fever 

and  diphtheria,  7 
Management  of  hospitals,  175 
Marshall,  Prof.,  on  circular  wards,  127 
Mattress,  144 
Maxwell  Ross,  Dr. ,  on  spread  of  measles 

and  scarlet  fever,  7 
Measles,  infection  of,  73 

mortality  from,   at  different  ages,  23, 

26 
spread  of,  7 
Medical  Officer,  175 
Metropolitan  Asylums  District  Board — 
rates  of  mortality  in  hospitals  of,       36 
diphtheria  ,,  20 

regulations  for  nurses  ,,  180 

for  visitors  to  ,,  182 

for  Ambulance  Station,    ,,  188 

scarlet  fever  ,,  ig 

typhoid  fever  ,,  17 

typhus  fever  ,,  15 

Micro-organisms,  pathogenic,  live  outside 
the  human  body,  68 
in  the  air,  floor  and  walls  of  wards,  74 
Mortality,  rate  of,  for  diphtheria,  36 
scarlet  fever,  36 
smallpox,  36 
typhoid  fever,  36 
typhus  fever,  36 
Morris,  Dr.  Caspar,  on  hospital  site,  104 
Mortuary,  143 

Mouatt  and  Snell,  on  hospital  site,  104 
Murchison,  Dr. ,  on  typhoid  fever,  1 8 

on  typhus  fever,  16 
Murphy,   Dr.,  on  dissemination   of  dis- 
ease from  hospitals,  91 
on  removal  of  patients,  83 

Naegili  and  pure  culture,  60 
Newcastle  Fever  Hospital,  distance  from 

houses,  g2 
Newsholme,  Dr. ,  on  vital  statistics,  35 
Nightingale,    Miss   Florence,    on  horse- 
hair mattress,  144 
.    on  hospital  site,  89 

on   one-storied  wards    and    detached 
pavilions,  103 

on  ventilation  and  warming,  132 
Notification  Act,  Infectious  Diseases,  53 
Nurses,  178 

ambulance  nurses,  193-202 

regulations  for,  180-202 

rooms  for,  138 

Office,  Ambulance  Station,  198 
Ogilvie  Grant,  Dr. ,  on  spread  of  measles, 

7 
Ogle,  Dr. ,  on  typhoid  fever,  70 

Page,  Dr. ,  on  use  of  hospital  for  pre- 
venting spread  of  disease,  52 


246 


PREVENTION  OF  EPIDEMICS 


Parsons,  Dr. ,  on  disinfection,  154 
on  horsehair  mattress,  145 
on  scarlet  fever,  8 
Passow  on  measles,  24 
Pasteur  on  hydrophobia,  13 
Patients,  removal  of,  82 

regulations  for  removal  of,  188 
Plans,  Hospitals — 

Circular    ward,     Burdon     Sanderson, 

appendix,  242 
Dunoon    and     Kilmun    Combination 

Hospital,  appendix,  232 
Ealing    Isolation  Hospital,  appendix, 

226 
Leamington   Infectious   Disease   Hos- 
pital, appendix,  217 
Local    Government    Board    plans    of 

hospitals,  appendix,  235 
Sheffield  Infectious  Hospital,  appendix, 

229 
Stonehouse    Isolation    Hospital,     ap- 
pendix, 228 
Tarbert  Isolation  Home,  appendix,  240 
Warrington   Infectious    Hospital,   ap- 
pendix, 223 
Poor,   hardships  to,   in  absence  of  hos- 
pitals, 47 
Population,  Scotland,  33 
number  of  beds  for,  80 
Powers,  Dr.,  on  diphtheria,  8 
Public  Health  Act,  5 

Regulations,  Ambulance  Station,  188 

nurses,  180 

Private  Sanitary  Aid  Association,  206 

visitors,  182 
Rich,  dangers  to,  40 
Roberts,  SirWm. ,  and  pure  culture  by 
heat,  60 

on  spontaneous  generation,  61 
Ross,    Dr.   Maxwell,    on    typhoid   fever, 

72 
Rural  districts,  infectious  diseases  in,  7 

infect  towns,  9 

remedial  measures  necessary  in,  10 
Russell,  Dr.,  on  boiling  water  as  a  disin- 
fectant, 166 

on  disinfection,  164 

on  incidence  of  epidemics,  9 

on  scarlet  fever,  8 
Russell,  Hon.  Rollo,  on  spread  of  diph- 
theria, 41 

Sanderson,  Dr.  Burdon,  on  antiseptics, 
75 

on  contagium,  57 

on  splenic  fever,  61 
Sanitary  Authorities,  County  Councils  as, 
87 

number  of  in  England,  4 
Sanitary  zone,  90 

Dr.  I'".  Brown  on,  105 

width  of,  93 


Scarlet  fever,  mortality  at  different  ages, 

19 

mortality,  decrease  of,  32 

spread  of,  7,  8 

streptococcus  of,  66 

traced  to  milk  supply,  8 

vitality  of  infection  of,  69 
Scotland,  families  in  houses  of  different 
sizes  (rural),  46 

population  of,  33 
Seaton,  Dr. ,  on  use  of  hospital  for  pre- 
venting spread  of  disease,  52 
Seclusion,  duration  of,  37 
Settle  Hospital,  expense  of  erecting,  79 
Sheffield    Infectious    Hospital,    plan    of, 

appendix,  229 
Simon,  Sir  John,  on  cleanliness,  185 

on  ill-kept  hospitals,  57 

on  wooden  hospitals,  120 
Site  of  hospital,  88,  89 

area  of,  106 

arrangement  of  buildings  on,  loi 

authorities  on,  102 

number  of  persons  per  acre  on,  106 
Smallpox,  decrease  in  mortality  from,  32 

mortality  at  different  ages  from,  29 

spread  of,  6,  7,  40 

vitality  of  infection  of,  69 
Smith,  Mr.    Percival  Gordon,   on  drain- 
age, 141 

on  inner  lining  of  walls,  126 

on  warming,  136 
Spears,  Mr. ,  on  woolsorters'  disease,  65 
Stonehouse  Isolation  Hospital,   plan  of, 

appendix,  228 
Sulphurous  acid  as  a  disinfectant,  162 
Superintendent,  Ambulance  Station,  202 

Tarbert  Isolation  Home,  plan  of,  ap- 
pendix, 240 
Thomas,  Dr. ,  on  mortality  from  measles, 

24 
Thomson    and    Rainy,   Drs. ,   on    air    of 

wards,  74 
Thorne  Thorne,  Dr. ,  on  admission  book, 
177 
on  distance  travelled  by  infection,  92 
on  effect  of  removing  patients,  spread 

of  disease,  50 
on  horse-hair  mattress,  145 
on  infection  of  diphtheria,  69 

typhoid  fever,  70 
on  inner  surface  of  walls,  126 
on  loans  for  hospitals,  4 
on  mortality  from  diphtheria,  22 
on  removal  of  patients,  84,  86 
Towns,  infection  never  extinct  in,  5 
infect  rural  districts,  9 
have  provided  means  for  isolation,  10 
Tripe,  Dr. ,  on  smallpox,  92 
Tuberculosis,  bacillus  of,  64 
Tyndall,  Prof.,  on  air  optically  pure,  61 
Typhoid  fever,  bacillus  of,  66 


INDEX 


247 


Typhoid  fever,  centres  of  infection,  43 
decrease  of,  for  24  years,  32 
mortality  at  different  ages  from,  17,  18 
spread  of,  8 
susceptibility  of  children  to,  17 

Typhus  fever,  decrease  of,  for  24  years, 

31 
in  general  hospitals,  98 
immunity  from,  59 
mortality  from  at  different  ages,  15 
Murchison,  Dr.,  statistics  of,  16 
West  of  Scotland,  49 

Uniforms,  Ambulance  Station,  200 

Ventilation,  132 

Ventilators,  136 

Visitors,  regulations  for,  182 

Walls  of  hospitals,  polishing  and  hard- 
ening of  vi'ooden  lining  of,  124 

inner  lining  of,  125 

retain  infection,  74 

space,  130 

thickness  of,  127 
Wards,  115 

circular,  127 

corrugated  iron,  122 

cubic  floor  and  wall  space  in,  130 

fallow,  151 

material  for  building,  117 


one-storied,  loi 

size  of,  129 

stone  or  brick,  125 

wooden,  118 
Warming,  132 
Warrington  Borough  Infectious  Hospital, 

appendix,  223 
Washington     Lyon's     disinfecting     ap- 
paratus, 169 
Wash-house,  142 
Water-closet  and  sink,  140 
Water  supply,  140 
Watt,  Dr. ,  on  spread  of  scarlet  fever,  7 

on  removal  of  patients,  85 
West,  Dr.,  on  whooping  cough,  27 
Whooping  cough,  27 

infection  of,  73 
Williams,  Dr.,  on  typhoid  fever,  8 
Windows,  131 

Wooden   hospitals,    Sir   J.    Simons   on, 
120 

pavilions,  118 
Woodhead,  Dr.,  on  diphtheria,  65 
Woolsorters'  disease,  65 
Wright,    Dr.,    on  value  of  isolation  to 

prevent  spread  of  smallpox,  51 
Wylie,    Dr.,    on    widely -detached    and 
one-storied  wards,  103 


Zymotic      diseases, 
from,  34' 


Scotland,      deaths 


THE    END 


Printed  by  R.  &  R.  Clark:,  Edinburgh 


"^^ 


DUE  DATE 

1 

f- 

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0    '-^^'-^^      : 

i  J  P'k-:' 

flw^S" 

■^ 

1 

201-6503 

Printed 
in  USA 

COUUMBt'l 


